MENDSTATE

AMAZING collaboration between military, USAID, and not-for-profit

2011-08-19T09:26:00.003-04:00

Wow! I recently heard a speech by Dr. William H. Foege, a world renowned epidemiologist who was key to the campaign that basically has eradicated smallpox (of course, with the exception of in Afghanistan and a few other war-torn areas), among other incredibly notable achievements. In his speech, Dr. Foege claimed that there would be an anti-malarial vaccine produced within the next 2-3 years, which is astonishing news from a very credible source.

This morning's news brings the announcement that the military, USAID and a not-for-profit called IDRI are collaborating to produce an anti-malarial vaccine. It's an incredible story, and if the effort is successful, the world will be changed. Here's the press release URL: http://m.prnewswire.com/news-releases/idri-usaid-strike-new-collaboration-for-malaria-vaccine-development-127868588.html.

I'm (slowly) writing a piece about the military's role in global health, and this kind of activity illustrates the real contributions that the U.S. government, writ large, can make. I hope it is successful!

Louie Palu photos and essay

2011-08-13T18:06:00.003-04:00

Photographer Louie Palau has a compelling piece on the Virginia Quarterly Review called "Total War" here at this URL:http://www.vqronline.org/articles/2010/spring/palu-total-war/, or click on this blog title. A Canadian doc tries to save an Afghan with a gut wound. His photos are evocative and powerful. I'd like to upload one to capture your attention, but I'm sure they are copyrighted.

Navy Corpsmen try to save an Afghan girl

2011-08-13T17:59:00.003-04:00

I came across some compelling journalism from Afghanistan (where else?) by a young guy named Elliott D. Woods in the Virginia Quarterly Review. There's a particularly germane piece on how some Corpsmen tried to save a little Afghan girl who was blown up by an IED. It's called "Our Deepest Sympathy." Worth looking over, truly, as are the rest of his stories from "Assignment Afghanistan" at this URL: http://www.assignmentafghanistan.org or click on the title of this post.

The Global Health Initiative

2011-06-26T08:30:00.002-04:00

The President's Global Health Initiative is great--nested within his policy for Foreign Development it lays out a way forward for health development. Eight countries were selected for "fast track" focus: Bangladesh, Ethiopia, Guatemala, Kenya, Malawi, Mali, Nepal and Rwanda. (I would have loved to watch the political debate about which countries were selected.) The paper posted on the White House website (click on the title of this blog to go there) says the eight countries:

will receive additional technical and management support to quickly implement and learn from GHI’s approach, including integrated programs and investments across the health priorities, fostering greater country ownership and targeting health systems activities that deliver results. These countries will provide enhanced opportunities to build upon existing public health programs; improve program performance; and work in close collaboration with partner governments, across U.S. government agencies, and with global partners.

The GHI is a $63 billion program. It will be interesting to see how this, and the foreign development programs, perform. And, I wonder how the DoD is focused on these priority countries, if at all?

More on sustainability

2011-06-20T14:21:00.003-04:00

Patricia McArdle wrote an oped descrying unsustainable development. She didn't point fingers at the military, this time, but did use the "s" word (sustainability) to advocate for solar and wind power. She apparently works for a solar cooker NGO. The punting around of the word sustainability is becoming almost comical, and I would laugh were I not so overwhelmingly wanting to bang my head against my desk when I read it.

CERP spending

2011-06-20T08:58:00.003-04:00

A good report on CERP spending appeared in the PRISM magazine (from the National Defense University) from March. It's one of the more balanced and insightful discussions about CERP spending. The debate about CERP spending is unending because there is no theory or reliable research being done to support the theory and inform a strategy. So there are many opinions, stated firmly and provocatively, but only partially informed. Get two people together over a cup of coffee with opinions on CERP and you have an automatic debate. In the end they each might be using the words "CERP spending" but talking about completely different contexts, uses, goals and outcomes. However, it will sound like a cogent debate. That's why we need more study, and less polemics (refering to my 2-part complaint about the Congressional report on foreign assistance).

Evaluating U.S. Foreign Assistance to Afghanistan-- A Two Part Complaint

2011-06-19T09:09:00.006-04:00

So, I've read the report prepared by the Senate Foreign Affairs Committee on assistance in Afghanistan and it's completely bizarre, as I feared. Here's how it starts:

"...we believe the administration can be more effective in how it spends aid in Afghanistan. U.S. assistance should meet three basic conditions before money is spent: our projects should be necessary, achievable, and sustainable." (page 2).

I wonder who wrote those two sentences? They are classic. Let's pause for one moment and examine the thesis of this incredible piece of work.

First, it says the administration can be more effective in how it spends aid. What does that mean, exactly? That the money should get more 'bang' for each 'buck'? For example, for every dollar spent, Afghans should get 60 cents in actual assistance -- like meals, water, roads and so forth? Because one OXFAM report claims that something like 40% of foreign assistance is returned to the country of initiation in salaries and payments to project managers and monitors from that country. OR, does that sentence mean that for every dollar spent we should see a resulting decrease in violence in any given area? Or, does that mean that for every dollar spent, the Afghan markets grow by some proportional amount? Or, perhaps it means that for every dollar spent, we should be able to get out of there faster? Or maybe that we have quicker mechanisms for spending the money? Congress appropriates it one day, and it's spent within a week or two? or...? No clear acknowledgement or recognition that money is being spent in Afghanistan in an incredibly complicated context strikes me as irresponsible.

Next, it says that "U.S. assistance should meet three basic conditions before money is spent: our projects should be necessary, achievable, and sustainable." Should US assistance be necessary, achievable and sustainable? Or should projects be necessary achievable and sustainable? Those are two separate things. Here's why.

First, let's look at assistance. Let's say the authors are trying to say that assistance should be necessary, achievable and sustainable. That would imply that there would be clear goals, objectives and programmatic for spending aid money in Afghanistan, which I can tell you is not happening. So, for a project like the District Delivery Program (which I have first hand knowledge of and which was a project to build sub-national governance), before spending money, USAID should have established what the overarching goal was, what the intermediate objectives were, and then how to determine whether those goals were met and the timeline for taking those measurements. If they did this, it was in secret. And I'm pretty sure that although there is some programmatic language for the billions that are being spent in Afghanistan, measures are not really measuring effects. Dear reader, you and I could dream up a great-sounding programmatic justification for spending money in Afghanistan. Delivering the results is quite another monster all together. Who knows if the planned actions are achievable in a war zone being conducted in a fourth world nation. And CERTAINLY the assistance is not sustainable by the Afghan government because that's why it's called assistance. If the Afghan government had enough money to spend on all the development international donors are supporting, then we wouldn't need to assist. Right? Or am I missing something here. Hopefully we are not giving money to countries that don't need assistance.

Next, let's look at the assertion from the standpoint that it means that projects should be necessary, achievable and sustainable. In a fourth world country, where literacy is about 25%, and life expectancy is about 45 years old, any spending can be justified. Any at all. The Afghans need everything. And the more we give, the more they need. What are we trying to achieve by all this giving? Well, that depends. In a lot of cases, we give because it makes us feel good. Soldiers spend money because they are shocked by the conditions, or because a local village leader buttered up a Marine and next thing you know the market has some brand new toilet facilities. USAID spends money because they are told to do so. They are being goaded, prodded and pushed into 'supporting the military' as they say in country. So, let's say all the expenses over the past year in Helmand province were to a) make us feel good, and b) show USAID support to military actions. Did they succeed? Well, you could go there and ask around--ask soldiers and aid workers if they felt good, and ask the military if USAID is spending dollars in support of operations. I think you would find positive results. So, the spending could right away be called necessary and achievable just based on those two justifications--feel good-ism and supporting the military. Are projects sustainable? No, because they are foreign assistance. We just went over that. Are the projects that are being constructed achievable? Yes, most everything is achievable, and very little is not getting completed. From cell phone towers to market toilets to roads to water turbines, projects are being completed all across Afghanistan.

The thesis for this report is askew and politically motivated. The report goes on to make many other circular claims. Like this one, on page 2. Most of the assistance is being spent on short term stabilization programs (undefined, of course). Notice the words "short" and "term". One paragraph later it complains:

"The evidence that stabilization programs promote stability in Afghanistan is limited. Some research suggests the opposite, and development best practices question the efficacy of using aid as a stabilization tool over the long run."

Notice the conflation of applying "development best practices" and "stabilization over the long run". And refer back to the discussion about how most money is being used for stabilization in the short run. So, if it's being used for short term gains, then what's the problem and why is the next paragraph discussing "development best practices" as if that's what is going on?

Another example of circular logic is here:

"The administration is pursuing an assistance strategy based on counterinsurgency theories that deserve careful, ongoing scrutiny to see if they yield intended results."

There is a confusion of reasons for spending in Afghanistan. Not all reasons are mutually exclusive. We could be spending money in a kinetic environment to, say, get a village cleaned up and the men back to doing something productive. It might also start boosting the micro-economic environment as people have a bit to spend and a small market might open up. This may be short-term gain, but it also might not be harmful to long term prosperity. It's a crapshoot. But it seems to me that the development folks are wisely questioning spending in support of a counterinsurgency campaign, but they are unwisely not questioning long term development practices as well. Because to be completely honest, we just don't know what's what and how best to spend money when in a post-conflict environment. It's all unknown and conditional.

Here's the real issue:

"There must also be unity of effort across the U.S. Government and international community. If we conclude that a civilian program lacks achievable goals and needs to be scaled back, no other actors should take over the effort. Too often, when our civilians determine that a project is infeasible, we simply transfer the program
to other actors, such as the U.S. military or other donors."

The report is more bluster than utility. All hat and no cattle.

Sustainability

2011-06-08T09:09:00.004-04:00

The Washington Post reported that a Congressional study will be released today that announces--shock of all shocks--the development in Afghanistan is NOT SUSTAINABLE! (Here's the post link: http://www.washingtonpost.com/national/national-security/afghan-nation-building-programs-not-sustainable-report-says/2011/06/07/AG5cPSLH_story.html)

Wow. Shock of all shocks--did we spend our tax dollars to come to this conclusion? Because they missed the question--sustainability is not The Question. The question should be: are we spending our development dollars to legitmize the Afghan government? It's all about legitimacy, not sustainability for Jimminy Cricket's sake. If you stop and examine the Afghan budget you'll find out that international donations OFF THE BUDGET account for about 82% of the total spending in Afghanistan, according to the Afghans. (And they can't really get their arms around all the spending. So it's probably more.) What does that mean? That means that for every 100 gazillion U.S. dollars donated by international donors, only 18 percent go thru the Afghan system and help build a government that can function and provide services, and the other 82 gazillion dollars go directly to contractors in the field who then do who-knows-what with it.

Normally, the sustainability mantra is leveled at DoD by the State Department and USAID, as if DoD spending is all the whole cause of "unsustainability" in Afghanistan. This is ridiculous and circular. The Development/Diplomacy community say that DoD should a) build sustainable structures, and not structures that fall down because the Afghans will be psychologically influenced (Seriously. No Joke, that's what they say.); and b) they also point to CERP spending and say that it's all unsustainable. SERIOUSLY? Here's the side of the argument that never gets discussed: there are only so many contractors in Afghanistan, and really, we are all using the same unskilled labor. USAID, for example, is building equally shaky roads, bridges and canals, buildings and so forth because we are all using the same unskilled labor! And, I'd like to know what survey shows that the Afghans will be psychologically influenced by the soundness of the development projects? The second argument is equally as bizarre. CERP spending is only a fraction of the total aid money being poured in to Afghanistan. When USAID, for example, builds a road, they also don't dump money into the ministry that is responsible for maintaining that road. Hence, the next winter/spring flood, the road washes out, and voila, the road was unsustainable, just as if CERP money had built it.

Even if you level the unsustainable argument against both the State Department and USAID and DoD all together, it still doesn't make sense. Because the bigger point that nobody wants to discuss because it's too hard, and it's much easier to wrangle among ourselves, is this question: if we don't dump money into a country like Afghanistan where there is about a 75% illiteracy rate, where people expect to live to the age of about 45, and where infant and maternal mortality rates are some of the worst in the world...then what is the alternative? I'd like to hear an alternative proposal from the development experts and the cast of staffers who concluded that aid to Afghanistan is not sustainable. (I wonder if they looked at aid to any other of the countries we assist? I'd bet they'd find out it too was not sustainable, because that's why it's called-- you guessed it-- aid. If the country could afford the programs itself, and thereby have sustainble programming, we wouldn't be giving it aid.)

Sustainability is one of those wonderful rosy terms that everyone likes to use--and of course, we can all agree that everything should be sustainable. But it's not pragmatic, and to my mind the wrong question for Afghanistan. The right question is: is our spending creating legitimacy? They are two different questions.

I'll be interested to see the Congressional report.

USAID feels bullied? Do we care?

2011-04-29T07:38:00.002-04:00

OK, I have to say that it's amazing to wake up in the morning, open the paper to read about how screwed up USAID is, and then read that they are feeling "bullied" into supporting military efforts in Afghanistan. First of all, who cares what they are feeling? I only bring this point up because in my experience, it's not uncommon to hear from USAID staff objections like this (in country) as if they are somehow valid and reasonable perspectives to be discussing in the middle of an armed conflict. Logically, how can you respond to this kind of statement? "Wow, sorry you feel bullied, shall we stop the war and have some apple tea and investigate those feelings?" "Tell me more about it? What in your childhood would bring this feeling up?" I know i am sounding snarky, but I absolutely cannot understand this institutional stance and culture. And it was constantly used in Afghanistan. Sorry, we can't make a decision on how to fund this MOST CRITICAL sub-national development program because we are considering how mean the military is. I actually sat in a meeting at the U.S. embassy where the senior leader spent 55 minutes in discourse about how awful it was that he didn't know the phone numbers of all the (5? or 7?) military people who were working in Afghan ministries. All he had to do was ask for a list and we would have provided it. Next topic! Like, I dunno, how to fund that most critical program?

I worked on a program called the District Delivery Program, which was really a pretty well-thought out program. It took USAID more than 3 months to review a 20-page document outlining costs that they had themselves helped to prepare and approve it. Three months is like an eternity in Afghanistan. Especially when we are going to experience a draw down soon. It was the oddest experience I have ever had. The people were great--smart, dedicated and diligent, but just nearly completely ineffective.

USAID has fielded all kinds of people into remote areas of Afghanistan with little strategy and/or supervision as well. That's part of the much-trumpted "civilian surge". They are bureacratically not set up to deal with what is going on in Afghanistan and they seem to be making no real attempts to amend their internal processes to the context. Probably because they are feeling bullied.

I know in one province that USAID was funding more than 50 programs and that NOBODY checked on those programs on a routine and systematic fashion. They didn't have the staff, the mobility, or the responsibility. That's your tax dollars hard at work. USAID routinely use the self-reported data from their contractors as their evaluation of their contracts. So for example, in the Post you can read that the primary contractor claims his program a huge success because he hired X,000 of hours of Afghans to clean their own canals. Really? Did anyone go check? I mean, if you ask me if my efforts were successful, and make award of my next pay check contingent on my own response, then yes, I can tell you that the work I do is probably the most valuable in the world, let me just think of how to describe it to you.

Here's the article in the Post: http://www.washingtonpost.com/world/us-military-dismayed-by-delays-in-3-key-development-projects-in-afghanistan/2011/04/22/AFD6jq8E_story.html?hpid=z2

The Soft Power Debate

2011-04-27T08:01:00.003-04:00

Kenneth Adelman takes aim at Joseph Nye's "Soft Power" construct in this Foreign Policy article: http://www.foreignpolicy.com/articles/2011/04/18/not_so_smart_power?page=full

"Huge recipients of U.S. foreign aid -- Egypt, Pakistan, and the like -- voted no more in tune with American values than similar countries that received no, or less, U.S. foreign aid. Instead, their votes correlated closely with those of Cuba, which wasn't a big foreign-aid donor.

That finding, surprising at the time, remains true. Four of the largest U.S. foreign-aid recipients today -- Egypt, Israel, Pakistan, and Afghanistan -- all take contrary positions on issues of critical importance to the White House. South Vietnam once got gobs -- gobs upon gobs -- of U.S. foreign aid. That didn't help much. Likewise with Egypt, Iran, Pakistan, Zaire (now the "Democratic" Republic of the Congo), and other "friendly" (read: graciously willing to take U.S. money) countries.

The conclusion seems clear: The relationship between "the United States' ability to positively influence events abroad," as Nye puts it, and the amount of U.S. foreign aid a country receives is unclear at best. For decades now, the United States has been the No. 1 foreign-aid donor -- it has given the most money to poor countries -- so it can't move up any on that scale. But this hasn't translated in making America the most popular or most influential country around the world. Quite the contrary."

I'm starting to be more and more skeptical of "soft power" myself. Especially when it seems to be used as an excuse to act upon our impulses to do good, rather than a real tool to promote American agendas AND do good. It seems, sometimes, as if we are a nation of dysfunctional d0-goodism, dumping billions of dollars of aid into places like Afghanistan where it ultimately fuels corruption and does little for the people. Less might be more, sometimes. The problem with "soft power" is that we indiscriminantly use that concept to dump aid with little measure of ROI (return on investment). And I'm even now beginning to think that we de-legitimize countries where we dump aid. Like Afghanistan.

UPMC Biosecurity Center

2011-04-25T20:16:00.002-04:00

Amazing what is getting posted on the web. Here's the University of Pittsburg Medical Center's Biosecurity Center's one-day seminar on US Investment in Global Health Security on YouTube: http://www.upmc-biosecurity.org/website/

Two-fer: Libya and Legitimacy

2011-04-23T07:47:00.005-04:00

Today's post has two themes: Libya (and where are the hospital ships?), and Legitimacy worries.

Yesterday's Washington Post ran a front-page photo of Libyans on board a ferry. The caption read that the ferry has been turned into a hospital ship, essentially. Which, of course, prompted me to figure out where is the Comfort and the Mercy. Odd that we are sending armed drones and special advisers, 'humanitarian defense equipment' like body armor and HMMWV's. But no relief capability. It strikes me as perhaps short sighted. Though, maybe not. I'll get to that in a moment.

Anyhow, I was looking around on the web to see where the Mercy and Comfort are, and found this interesting blog: http://blog.usni.org/2010/01/25/time-to-reactivate-the-usns-mercy-t-ah-19/

There was quite a lively debate about the Mercy and the Comfort. The Mercy website is not forthcoming with information about where it is at the moment, and it seems as if it might be in dry dock (from surfing various web pages). Here's the Mercy's web page: http://www.med.navy.mil/sites/usnsmercy/Pages/default.aspx

It seems like "soft power" is not an option at this moment, and I wonder why. Maybe our doctrine is too muddled? Maybe sending a hospital ship full of interagency partners to a war zone is a non-starter? Maybe we don't have an agile-enough capability? The Chinese hospital ship, the "Peace Ark" is nowhere to be found, at the moment, either. Tho I did find a note that the Chinese had offered it to the Japanese. (Yes, that's not a typo.) China is "all about" Aftica--it's resources will provide power to the Chinese for decades to come (while we are distractedly thinking of power in terms of military might). I was suprised that I didn't see the Peace Ark being offered up.

Back to my thoughts about the non-crisis humanitarian assistance missions of these ships: I was chatting with a colleague recently who has thought a lot about the legitimacy of governments-- or, the lack of legitimacy where these hospital ships do their service. It suddenly dawned on me that the U.S. might be cutting off its nose to spite its face, in a manner, with these non-crisis humanitarian missions. So, for example, in the context where DoD sends a hospital ship to a country that is not in conflict to provide medical care, there is a greater risk of further exposing the inability of the country's legitimate government to provide basic services to its citizens. Sort of an awkward sentence, so let me try again. What I'm suggesting is that in countries where there are fragile governments (most really poor countries), dependence on foreign assistance is generally endemic. There are typically a gazillion donors and NGOs earnestly working hard to help the people, and the people do not expect their own government to provide medical care (hypothetically).Even though DoD gets permission from the host-nation, I wonder if stopping in and doing some non-emergency humanitarian action might be good for the people who received the care, it might make us feel good about ourselves, but harming the overall system? Are we deligitimizing the already-fragile government? Has anyone studied this? Or are we happy to be doing great deeds of service, and hoping it all works out in the end.

That's the twofer today.

Google search trend tool

2011-04-21T22:14:00.002-04:00

Google has a really interesting search trend tool available. You can track search trends (like "military" shown on the right) across time and in location. It provides a graph indicating normalized trends as well as a graph that shows any news stories and volume of news stories related to the search trend. It's amazing!

Google searches can predict the flu!!

2011-04-21T21:29:00.008-04:00

Holy COW! I'm probably the last person in public health to know this, but the rate of google searches for "flu" closely matches the actual incidence of flu! I didn't read the journal article (yet) but you have GOT to look at this--it's amazing. The implications are huge. Google search as a surveillance tool is actually a really great idea!

"Google Flu Trends estimates flu activity for a number of countries by using aggregated search query data. The system provides users and public health officials with near real-time estimates of flu activity in their region. Traditional surveillance reports come directly from doctors and other health service professionals, sometimes with a delay of up to 1-2 weeks."

Here's the URL (or click on the heading)

http://www.google.org/flutrends/about/how.html

Team Rubicon

2011-04-16T19:44:00.003-04:00

And here is a group of enterprising former military guys doing good. Team Rubicon (also, there's an interesting explanation of them on Ted): http://teamrubiconusa.org/

They like to hire veterans because veterans like to serve. I'm too much of a nerd to go along with that (my brain: wait, what's the incidence of volunteerism for volunteerism sake in the general population as compared to the incidence in the military? hmmmm would make a good dissertation). Nonetheless, it's interesting. And cool and adventurous. One of their friends and colleagues, a young former Marine, committed suicide. It's tragic to read about.

DoD video about Medical Stability Operations

2011-04-16T19:40:00.003-04:00

Check out DoD's video about Haiti at this link: http://intlhealth.fhpr.osd.mil/videosIDIntCivMilPrthps.mil.aspx

USAID is going to be more effective

2011-04-14T17:00:00.004-04:00

Robert Swope over at D3 (http://www.robertswope.com/) posted the contents of a speech by Rajiv Shah, the USAID Administrator. The upshot of the speech: USAID programs are going to be monitored and evaluated for their effectiveness. While I applaud this thought, I wonder how this will be accomplished. USAID is essentially a huge contracting agency. The agency cuts contracts with local NGOs (called "implementing partners") to do the work, and other contractors to see if the work was done (or they just let the implementing partner report about how the work was getting done). In one province in remote Afghanistan, for example, there were allegely more than 50 programs on going. There was one USAID representative and it was not his job to see if the women in the job program were actually getting the required literacy training or not. He spent his day at the FOB because he had no transportation. This is not the entire picture, by the way, of what USAID does--there were numerous incredibly dedicated individuals posted to remote and dangerous locations all by themselves living off the military (again-- a somewhat hostile relationship) doing great work. But in terms of contracting...no way USAID has any idea about what's going on in all those contracts all over Afghanistan. No Way. So, how to implement some kind of control? Well, that would require growing the organization to do monitoring. That's not going to happen obviously. We'll just have to wait to see how this plays out. It's a good idea, but I am not sure it's feasible.

Here's the speech:http://www.usaid.gov/press/speeches/2011/sp110119.html

Where Have I Been?

2011-04-14T16:35:00.002-04:00

I've been back from Afghanistan for about 6 months now. The time has shot by. But my thoughts keep returning. It's not uncommon, actually, and I wonder if it's some kind of sickness?

In any case, where I have been? Trying to get reestablished at work, to begin with. Trying to piece together relationships that probably felt abandoned by friends and colleagues. Although the internet is a help, we didn't have real access during my time in Afghanistan. And I was only gone from home for about 15 months total.

I've been watching and reading the "3D" debate again--reading how swimmingly things are going in the "interagency". This completely contradicts my experiences in Afghanistan where the diplomatic and development circles hated people in uniform. Just because we wore the uniform. The hatred and tension was indescribable. I'd like to write about it, or even perhaps make a web product with interviews and short articles, perhaps video clips illustrating the hatred felt on both sides. How are we to succeed when there is this much tension and hatred? The Afghans play us against each other, too. So while the pundits back in DC make their personal fortunes talking about how great it is that the S/CRS office is up and running here in DC, there is little discussion about the embattled PRTs or civilian platforms in Afghanistan. It's ridiculous.

It feels overwhelming to read things here about how we are getting along when in reality, where it REALLY COUNTS (e.g. in Afghanistan or even in Iraq still) we are not getting along. If the taxpayer only knew.

I've been debating whether to keep this blog going, to post, think about this issue more or just move on. I am still not clear, to be honest. I have such a dirty feeling about the entire experience, I'm not sure I want to wallow in it. Then again, sometimes these fights and issues are those most worth thinking about.

So that's where I've been-- putting my life back together, doing yard work, getting in to the swing of things at work, celebrating a friend's new citizenship, going out to dinner. All these activities that I didn't get to do while I was in training and then deployed. It's a good life we lead. Deceptively good. We are priviledged people. I think I'll keep posting things and developing this blog little by little. After all, it's the community that's the prize, to paraphrase from a friend in the US Embassy in Kabul.

New Journal of Global Health

2011-02-27T09:19:00.002-05:00

It looks like Columbia University is creating a new journal of Global Health (URL here: http://www.ghjournal.org/). It claims that it will be more solutions oriented. There is a call for submissions to the first edition right now. I will be interested to see what the themes will break down to be. What strikes me about Global Health is that the field work is done in 'silos' -- by disease. Of course this is often driven by funding sources. Polio-interested money drives polio campaigns regardless of other contextual problems which might be more urgent. And I'm not picking on Polio campaigns, just using that as an example.

The Militarization of Aid

2011-02-11T14:33:00.002-05:00

Haven't had a chance to read this yet, but the Harvard Political Review has a pretty good overview of the debate about the militarization of aid. What's amazing about this issue is that it's one sided. The military really doesn't have a view about it. I suppose if aid agencies started fighting wars, the defense department might have some heartache.

Here's the link: http://hpronline.org/arusa/the-3ds-of-foreign-affairs

Army Reserve and National Guard Suicide Rates

2011-01-20T17:13:00.004-05:00

Interesting reports today about increased suicide rates in the Army Reserve and National Guard. I haven't looked at the actual data, but I wonder if the rates are actually increased or if the reporting has improved both in terms of quality and quantity, hence we now know more about the population. We don't actually know that much about the Reserve and National Guard population because it is so transitory. It only gets together one time a month. Units are being filled with people from various parts of the US for deployment then split up again once everyone comes home.

I can say that I dearly miss the colleagues I served with in Afghanistan. We are spread across the Southeastern US, rather than in a one-block radius on a military post in Kabul. Many were added to my reserve unit at the last minute--me included--and we were the "loose ends" group, as one of my friends called us. Always behind in training, always at late night sessions trying to catch up while the rest of the unit prepared. I don't know if their mental health is poor--they are too far away, and I am too consumed with getting myself back to work to tune in to them. We have texted and called for brief chats. Amazingly, I didn't have time to have a "social" life in Afghanistan, working 16 hour days, but I knew that they were always there. Funny people with vivid interesting lives, doing the best they could do in a hard environment. And now there's a little hole where they were. I'm back at work in a supportive environment, with super colleagues. But most have never worn body armor, fired an M4, run to catch a helo carrying 40 pounds of gear in 120 degree heat while herding frightened Afghans and trying to act like the situation was all normal, or worse yet, stood at a memorial for 5 young soldiers killed by a crazed attacker, or hung out with a 3-star general at 1:30 in the morning and listened to his stories of other's bravery and loss, watching him weep and laugh under the pallid flourescent lights. While I'm glad to be home, it's just a different world, with its own demands and rigors. If you come home and don't have support, I can see where your spirit would nosedive.

war or health?

2011-01-19T18:27:00.000-05:00

2011-01-19T18:23:00.000-05:00

Blood and Milk Blog

2011-01-19T18:12:00.002-05:00

So, I'm slow on the uptake here. I just figured out that there's a brilliant blogger who has been blogging about International Aid and Public Health for quite a while, and who has even contributed comments to one of my rants. Check out the Blood and Milk Blog for some good reading.

The Great "Pointing of Fingers" Game: USAID and NGOs versus DoD.

2011-01-18T09:48:00.007-05:00

The Washington Post ran a series two weeks ago about the issues surrounding the military's use of the Commander's Emergency Response Program monies to rebuild Iraq and Afghanistan. Nothing new was divulged--the program is unproven and therefore subject to attack. There is no real strategy for its use, and examples of wasted effort abound. Ho hum.

A letter to the editor appeared in response to the articles, which I have copied:

Washington Post
January 11, 2011
Military-Led Aid Projects Doomed To Fail In Afghanistan
It is no surprise that military aid projects in Afghanistan are "crumbling under Afghan stewardship" ["In Afghan hands, aid projects neglected," front page, Jan. 4]. The troops are armed with good intentions, but they often neglect basic development principles, owing to a lack of expertise on aid and mounting military and political pressures.

Afghanistan's National Solidarity Program is a better alternative. Under this proven model, called "community-driven reconstruction," local engagement and accountability are as important as bricks and mortar. Afghan staff members from agencies such as mine help organize village groups and determine what they need most and who will be responsible for the viability of a school, clinic or road. It's laborious work that emphasizes local knowledge and local ownership as well as sustained commitment - indispensable if Afghanistan development is to have any hope of success.

Military-led projects erode established humanitarian principles of impartiality and independence, fail to win hearts and minds and - we now know - are ineffective. The White House, the State Department, the Pentagon and Congress need to act on the growing evidence showing that the militarization of aid is folly.

Michael Kocher, New York
The writer is vice president for International Programs at the International Rescue Committee.
Editor's Note: The article by Josh Boak appeared in the Current News Early Bird, January 4, 2011.

The author is elegant in his ability to touch on all the "points" against DoD, making bizarre assertions based on faulty assumptions that are oft repeated. For example, in his editorial about Afghanistan, Mr. Kocher claims that "military-led projects erode established humanitarian practices...". I wonder if Mr. Kocher realizes that there is a war in Afghanistan? The military is not engaged in trying to influence the social development of Afghanistan for humanitarian reasons, but rather as a way to win the counter insurgency.

Second, the Afghan National Solidarity Program is not "proven", nor is it an alternative. Afghanistan is not a landscape that can only contain EITHER the military OR the Afghan National Solidary Program as the author seems to assert. And particularly since neither program is proven.

Finally, the conclusion that Congress et al should act on 'growing evidence' against militarization of aid is quite a leap of logic. Wait, I thought we were talking about Afghanistan?

The continued rhetoric from USAID and the NGOs against the military is provocative, for sure. However it's not neccessarily productive. What is needed is less provocation and more serious analysis and discourse about the complicated context we find ourselves in. The continued claims against the military's effectiveness at 'nation building' are well worth investigating. The pragmatic problem, however, is that there are no alternatives regardless of what any analysis would find. For example, in Afghanistan, it was my experience that USAID wouldn't work in areas which are too unsafe (undefined), and they also won't work in areas which are too safe and developed as it would be a waste of resources. Sure, the military is inefficient and cumbersome and makes mistakes. Inexpert. But what's the alternative? The cries from USAID and the NGOs would be more effective if they were backed up with an alternative course of action that is proven and effective. As the book "The White Man's Burden" describes, we have spent billions in aid and assistance, and yet the world seems no more friendly nor less impoverished.

War and Health blogs

2011-01-14T13:29:00.003-05:00

You've got to hand it to War and Health/Conflict Health guru (nearly as insane as being called a "Drug Czar") Chris Albon. PhD candidate and world traveller, Chris has NEVER missed a beat. While I was contributing to the mire in the land-of-no-internet (aka a NATO command in Afghanistan), Chris was in South Africa with an equally challenging lack of internet access. The difference was that he somehow managed to maintain his blog and I did not. This editorial, highlighted by Chris is really interesting: http://conflicthealth.com/must-read-jefferson%e2%80%99s-army-of-nation-builders/.

Hats off to the brilliant Chris Albon. Read Conflict Health early and often. There aren't many blogs with such high quality and relevancy.

Mortality rates decrease in Afghanistan

2011-01-14T12:51:00.003-05:00

http://www.nytimes.com/2011/01/08/world/asia/08wounded.html

The New York Times has an interesting article about the reduction in mortality rates from injuries in Afghanistan.

News Flash: Climate Change will cause Disease

2011-01-13T13:19:00.003-05:00

So, the drum beat of disease as a national security threat continues. Nothing new in this piece in the Kansas City press (click on title), but I have Laurie Garrett's book, "Betrayal of Trust" here on my desk in line to be read. It will be interesting to see if this crescendos -- issues seem to wax and wane.

New Assistant Secretary of Defense for Health Affairs

2011-01-13T06:46:00.002-05:00

Dr. Jonathan Woodson has finally been confirmed as the new Assistant Secretary of Defense for Health Affairs! This is good news. TRICARE is the largest health care system in the world and the Assistant Secretary runs it, as well as the extended rest of the military health system. There is mounting pressure to reduce the costs of providing health care services to beneficiaries (which number around 9.6 million and include soldiers in Afghanistan, retirees in Germany, and families here in the states). The acting secretaries (which have been numerous) can only 'stay the course' and not make any significant changes. Hence any reform is nearly impossible. So it is good news that we finally have someone appointed, and shame on Congress for taking so long as Dr. Woodson was nominated in April of 2010.

Biological Warfare: "1491" by Charles C. Mann

2010-12-29T08:36:00.004-05:00

An amazing read! Charles C. Mann's book "1491" describes the possibility that native American contact with European traders may have depopulated the continent in advance of the arrival of colonists via spread of disease. Hence, when the colonists arrived, they found a relatively sparsely populated countryside. This context then gives rise our cultural imagination of the native population as 'primitives' living in a relatively uncultured and somewhat 'ecologically harmonious' and naive state.

Biological relativism is also debunked in Appendix C. European disease obliterated native American cultures, and the natural question arises--what diseases originated on this continent that had the same effect on Europeans? One oft-repeated answer: syphilis. The first recorded European outbreak of syphilis occurred around 1494-1495, brought back by mercenaries working for Charles VIII of France's armies in their conquest of Naples. As Charles' army fled a counter attack, mercenaries split off from the main retreating body, spreading syphilis as they went via their habit of rape and pillage. Within a year, European cities were banishing people who suffered from syphilis. It's not clear whether the disease came from American with Columbus' returning voyage, as suggested, with an equal number of arguments for and against. Hence any positive assertion of biological symmetry is sketchy at best. Mann makes the point that while smallpox toppled empires, syphilis did not, even if it did come from the Americas.

This book is interesting beyond the war-health perspective and will debunk many myths built up from years of TV, Hollywood movies, childhood fiction, and junior high text books.

The Battle of Towton: Human remains tell the story of a battle fought 500 years ago

2010-12-29T08:20:00.003-05:00

The December 18th-31st issue of The Economist has an interesting article about archaeological excavations of the Battle of Towton which occurred March 29, 1461 in England. By examining the bones found in a mass grave site, archaeologists found that the fighters (for they were not professional soldiers) were taller than the popular imagination makes them--just 4 cm shorter than current Englishmen. Poor nutrition and disease caused stunting later-- in the Victorian era. The longbow was the primary weapon, and evidence shows thickening of the upper right arm bone near the shoulder and the left arm near the elbow, in response to the bow's use. Also, the battle was the scene of the earliest use of gunpowder, and archaeologists think they may have found a fragment of a handgun. The stress of the battle was so enormous that the fighters clenched their teeth together hard enough to cause splintering.

The history of foreign aid: "Samaritan Diplomacy"?

2010-12-28T18:01:00.004-05:00

Not only am I back from Afghanistan, where I had extremely limited access to the internet both in terms of time and actual connectivity, but I am also back from a 2 month long "victory lap," as a friend called it, of the U.S. I got to see great America, and it was great! Starting at the Statue of Liberty and heading west (with a northerly detour to Niagara falls) I got to see all those iconic US spots that I hadn't previously seen (the corn palace in Mitchell, SD; Mount Rushmore; Grand Canyon; Petrified Forest and the Painted Desert...you get the idea).

Now that Christmas is done and I can start to settle in, I am doing some reading. In my travels I found the third book of Daniel J. Boorstin's series called "The Americans", the third book is called "The Democractic Experience" published in 1974. At the end of the book he discusses "Samaritan Diplomacy" and the changes in US perspective from pre-Marshall plan when aid to other nations was considered unconstitutional, to post-Marshall plan when US aid was expanded beyond war reparations and European nations to under developed nations. (It was first expanded by Truman in his "fourth point".)

Boorstin starts this section off: "For most of the nation's history, the United States remained uncomfortable, inept and on the whole unsuccessful in diplomacy." (p 568) Interestingly, one of the first acts using the military for aid came in 1880 during one of the Irish potato famines. Congress passed a joint resolution that allowed the Secretary of the navy to use a naval vessel to carry volutary (privately donated) relief to the Irish. Later, this was regarded as a regrettable stretching of the Constitution to appease the Irish-American vote.

According to Boorstin, not until the Marshall plan was there enough political justification to use American tax money to assist other nations. The confusion of motives for the aid stems from this time: "The American institution of foreign aid was a by-product of World War II. It marked a new stage in American foreign policy in which charitable, fiscal, political, ideological, and military motives would be more confused than ever before. Incidentally, too, foreign aid would newly confuse the techniques, attitudes, and institutions of peace with those of war, and so would help open an era in American foreign relations when the American people were neither at war nor at peace." (p 574) Boorstin claims that "except in religious missions, the nation had no substantial precendent for a world-wide program of foreign aid....foreign aid now expressed faith that American wealth could raise the standard of living of people anywhere. A people with a higher, more nearly American standard of living, it was assumed, would be more apt to be democratic, and hence more apt to be peace-loving and friendly to the United States. Implied, also was the complementary assumption that poverty, misery and industrial backwardness would make any people less peaceful and less democratic, hence more prone to communism, and therefore more inclined to join the enemies of the United States." Of course, the assumptions have not always born out.

In fact, this discussion gave me pause, particularly in light of the steady drum beat of the Millenium Development Goals, the political and military discourse about globalization and "haves" versus "have nots", and the confusion over the common use of the term "humanitarian aid" (for purely humanitarian reasons? or for political motives?)

Also relevant, the theory of counter insurgency calls for massive development expenditures in dangerous areas in order to create sympathies for the legitimate government, in order to assist people attain their basic life needs--water food shelter--so they feel better about their government and 'buy in' to it's legitimacy, lay down arms and stop harboring terrorists. But, as pointed out in the Washington Post front page yesterday, it's not that easy. USAID and the US State Department in Afghanistan, for example, only want the military to provide "security" so they can provide development assistance. Yet their vision of security and the military version are disparate. And sometimes discussions about where to deliver development assistance veer toward the absurd when geographical areas are deemed "too safe" for development assistance and other areas not safe enough. USAID doesn't want to deliver aid where it's unsafe, and they don't want to waste their aid on places where it's too safe. And they damn sure don't want the military to meddle in their humanitarian space (as they call the battlefield) by delivering aid or creating development projects.

Boorstin had it right. It's a confusion that is not about to go away. Are we confusing the world with our own confusion? Is "smart power" truly smart?

Ashraf Ghani

2010-10-30T06:40:00.008-04:00

Kabul Afghanistan has terrific weather. Dry air, cool evenings, sunny days...weather that you would happily consider retiring to. On a balmy evening last spring, when the air was just warm enough to feel soft on your skin, the breeze light and not forbidding, and the sun was just setting over the mountains so the sky was pastel ivory and pink, I was scurrying from my desk to dinner when I ran in to Lieutenant General Rodriguez standing outside the headquarters building waiting for someone. I snapped a salute and he saluted me back, then engaged me in a moment of pleasant chatter. I was honored, of course, that such an important man would engage me. Honored? No, more like stunned. Blinking up at him and smiling. Probably saying stupid things, or at the very least, trying to think of non-stupid things to say. In the midst of this inner turmoil, LG Rodriguez then changed the topic -- asked me for a favor, even. Of course, I replied. Ashraf Ghani is coming, he said, and he had left some important papers on his desk--would I fetch the papers? Who ME? I'd LOVE to fetch the papers, of course, right away Sir. I had never even thought about approaching the Inner Inner sanctum-- the General's Office-- which is revered and feared much like the elementary school Principal's office. I scurried back into the building to fetch the papers. Who is Ashraf Ghani, I wondered? Didn't he run for president, maybe?

Darted into the General's office, found the papers, darted out. The sun had sunk just below the mountain peak way off in the west. The General looked at the papers, then looked up at the mountains, and smiled and thanked me as if I had just done something important. I considered leveraging my moment of glory to ask who is Ashraf Ghani? But just as I was considering, a white pickup bristling with Afghans and guns zoomed up followed by an armored SUV. As if choreographed, the moment the vehicles slowed just enough, a beautiful man in flowing robes exited the SUV with a smile. As if Venus alighting from the Clamshell I remarked, surprised. He warmly grasped LG Rodriguez's hand and they swished in to the building for their meeting. Clearly Ashraf Ghani was someone. No, I mean Someone. Big S. A colleague passed me by on the street just then and said, that was Ashraf Ghani. He's the most wanted man in Afghanistan. What? I asked. He didn't look hunted. He looked angelic! We laughed.

Turned out Ashraf Ghani had run for president of Afghanistan, and has done so much more. He was the finance minister for Afghanistan, he is an advisor to Afghan President Karzai, and he is a reformer of international aid, former World Bank Employee. He runs the Institute for State Effectiveness. That was what my google search turned up.

Less than a month later I was in Kandahar. Kandahar has weather that you would not retire to. Dry, boiling hot and dusty. It's flat there, with odd spires of rock that protrude from the desert floor like the spines on a reptile's back. The dust is a soft powder brown and as you sweat, it sticks to you in a fine even coat. The only nice weather is at sunset when the sky turns rosy and the call to prayer meanders across the desert floor like steam from a tea cup, redolent with ancient meaning. I was down in Kandahar on business, waiting for my flight home, tired, perusing the 'donated books' shelf. My body armor already on, I felt hot, sweaty, distracted. I just needed something to read for the trip back to Kabul. Lots of science fiction floats around these donated book shelves, romance novels and other relatively unidentifiable material, mostly with eye-catching covers and little substance in between. I scanned the shelves, nothing. Then, in the very corner of a shelf I saw a hard bound book. Those are not usual, so I focused...Ashraf Ghani and Clare Lockhart "Fixing Failed States". What? Ashraf Ghani! The most wanted man in Afghanistan!! (I don't know if this is true, but of course it's the kind of thing you would remember). Gotta read it.

Here's a link to Ashraf Ghani and Clare Lockhart's Institute for State Effectiveness: http://www.effectivestates.org/. One of the themes Ashraf Ghani and Clare Lockhart return to in the book and other writing is the incoherence of the 'intervening' states' programs. By that I mean the incoherence of the aid agencies of various countries as well as the incoherence of programs between the aid agencies and the military. Generally speaking, as various donor nations seek ways to support a weak government, they take on individual programs and projects and then become protective of those programs, competitive, even. The agencies compete with each other to place 'technical advisers' in the nation's governmental organizations. The technical advisers report back to their country, promote their own programs above others and compete for time with the top ministry staff and ministers themselves. Government agencies and officials are often whipsawed between competing demands made more salient by associated programmatic funds. Many nations also pay for top up salaries to high-ranking national staff and ministers, with the richer nations creating a competitive environment for ministerial staff to play one nation against the other. The military is often involved not because of the money and expertise it brings, but because of its sheer massive size and presence. It's wasteful and generally counterproductive. And Ashraf Ghani and Clare Lockhart speak out about it. After reading the book, I wonder if Ashraf is the most wanted by aid agency staff as opposed to nefarious Afghan characters?

Here is a link to a report describing the results of an exercise conducted by the Center for American Progress that tested reforms needed in the U.S. Government's approach to nation building: http://www.americanprogress.org/issues/2009/03/swords_ploughshares.html. They
recommend, not surprisingly, that counterinsurgency and development strategy must be harmonized. But how.

Last spring, back in Kabul, the higher-ups, as senior officials are sometimes called, demanded a description of civil-military cooperation. ISAF and donor nation embassies and aid organizations all gathered together for a formalized briefing of how we all were cooperating. It looked great on the slides. The civilian diplomatic and development community were hard at work pouring billions of dollars into a financial system that can't absorb the money, and the military was diligently fighting insurgents. Meetings had been conducted, and programs were in place. It looked well.

But the problem for us to consider is whether the Afghan woman who lives in a village really could feel the difference? Could that woman really feel that their own government had finally gathered itself up and provided her electricity or water? I would guess not. Not in most places where the combined community claims to be engaged, anyhow. To be fair, there are successes--Kandahar and Helmand province, some places in the East and the West. But not the scope nor the depth of effectiveness that one might (falsely?) expect given the vast resources being poured in to the country. This is the crux of the matter, the proverbial hard-nut-to-crack. The community has not really changed enough to make it matter, even in spite of the millions of pages written and billions of dollars poured.

I'm writing a paper on this, and when I'm done I'll post the nuggets here. I don't pretend to have the all the answers, but the problem was one I lived for 16 hours a day, 7 days a week, and its glare will not leave me. I dream about this problem. So I have to write about it. Meanwhile I'm re-reading Fixing Failed States which I sent home to myself. Ghani and Lockhart probably have all the answers: at least I hope they do.

Back from Afghanistan

2010-10-20T08:08:00.004-04:00

I am just back from Afghanistan and intend to start blogging again. I have many impressions to share about the war, Afghanistan, and the "interagency". Civ-Mil cooperation, as it is called, is certainly a focus, though the actual effect of what cooperation there is is difficult to assess.

My first blog, however, must be a description of my work in Afghanistan to provide context.

Imagine a rectangle with a 1.25 mile perimeter. Fill the rectangle with generators, 16-person tents, some brick 2-story barracks, tons of large-grade grey gravel and a brick gymnasium and you now are imagining the headquarters where I and my NATO colleagues toiled for 16 or more hours a day, every day with only a few hours off every week. (A visitor to the compound once stopped me and asked me "Is the dining facility the building next to the prison?" My reply: "The prison? OH! That's not a prison, it's our command building--that's where everyone works!") The ISAF Joint Command, a newly-formed operational command hums and clicks 24 hours a day, 7 days a week. The dream child of a select group of officers, IJC (as the ISAF Joint Command is called) has a fabulously novel and famously complex structure that breaks military convention, for good reason. Instead of a normal structure where all the people who deal with transportation sit together in an isolated office, and all the people who make military plans sit in another isolated office, and all the intelligence officers sit behind several layers of barbed wire and chain link fence, the IJC has four teams of people drawn from each specialty area who work together. The four groups are planning teams that are organized according to a time horizon: Current operations, the group that monitors and makes plans on ongoing operations; Future Operations (where I worked) that planned for near-term operations; Future Operations that planned long-term operations; and then the Information Dominance Center that collected and analyzed information and fed the other three teams. (Here's an article about the structure and the Information Dominance Center: http://www.afcea.org/signal/articles/templates/Signal_Article_Template.asp?articleid=2250&zoneid=292 )

The beauty of the system is that I (a "stability planner" or Civil Affairs planner) was able to interact with the military planners, transportation planners and intelligence officers day in and day out in order to better understand the complex context of our operations. It is an incredibly information-rich and productive structure. Many officers, particularly the senior officers, have significant trouble understanding their role in this 'new' structure because it break down the rank-authority barriers to a large degree. I enjoyed this facet of the structure because it allowed me to participate more fully.

I worked on two topic areas: building sub-national governance and then at the end of my time working with the western and northern regional commands to support their governance and development operations. It was extremely fulfilling, complicated, important, and frustrating work. I loved my time there. As one of my bosses, COL Wayne Grigsby, would say "This is God's work." Amen to that.

I published an information piece in the Small Wars Journal on the subnational-governance-building piece of my work: http://smallwarsjournal.com/blog/journal/docs-temp/489-fisher.pdf
I'm writing a follow-on piece about this program.

I'm glad to be home--the air here is clean and cool, fall is just starting, there are no generators, no dust, no rocket attacks. The land here is fertile and sustaining, our lifestyles so rich and so easy. I am thankful to be an American and proud to have served with so many dedicated, determined, intelligent and thoughtful officers. I have learned to be a better person from them and the Afghans I worked with, as well as a better military officer.

Is it a battlespace or is it "humanitarian space"?

2009-07-27T16:08:00.005-04:00

My colleague Dr. Gene Bonventre has been hard at work considering ways to get USAID to work with DoD. One of the irritating fundamental arguments I have heard from USAID/DoS and NGO personnel against DoD's work is that we are 'crowding the humanitarian space'. Part of the problem, in my view, is that DoD doesn't view where it works as "humanitarian space." Afghanistan, for example, is a "battlespace" in my view. Some USAID personnel do not share that view and believe the country to be a "humanitarian space" that is being poisoned by DoD. In fact, some would argue that DoD's presence in Afghanistan creates danger to their personnel. From the DoD perspective, the U.S. President ordered up a war against the Taliban who were lurking in Afghanistan.

But back to the brilliant Dr. Bonventre who used to work for DoD. He apparently has been slaving away on a committee to make recommendations about how we can all get along. The report is here: http://www.usaid.gov/km/seminars/2009/civilian_military_relations.pdf. I haven't read it thoroughly yet but it looks promising.

Also, Dr. Bonventre and another brilliant former military guy, Dr. Skip Burkle, have posted their views here, on the New Security Beat blog ( http://newsecuritybeat.blogspot.com/2009/07/who-does-development-guest-contributor.html?showComment=1248726308123#c3239810732797271218).

I take issue with Skip Burkle's blog in that he views the discussion from a development perspective (the title of the blog, after all), and he maintains that USAID is best for development actions. He criticizes Secretary Gates for asking for more civilian personnel positing that Gates was asking for the personnel to be under the control of the military. Finally he criticizes DoD for be inexpert at development which he calls "winning hearts and minds" and which I would argue is "counter insurgency" when referring to Afghanistan and Pakistan. Regardless of his critique I think the question is the wrong question.

I don't think we have the luxury to have "either/or" agencies any more. I have written about this before--I think Michele Flournoy hit the nail on the head with a proposal for a new breed of security expert. Or, you could have a new breed of development expert. Either way, staff at USAID who are being paid with my tax dollars should be promoting the US Government agenda, and part of that is our national security interests. Cognizance of what that is would be a good starting point. Much like we can no longer leave military actions in these hybrid wars to the combat arms dudes who view every problem as something to shoot and kill. The world has moved on, but perhaps our gut reactions have not.

Nat. Mus. of Health and Medicine - Resolved exhibit

2009-07-20T21:25:00.001-04:00

Nat. Mus. of Health and Medicine - Resolved exhibit
Originally uploaded by etacar11

Healthcare not Warfare protests in the U.S.

2009-07-20T21:21:00.001-04:00

the health care perspective
Originally uploaded by redletterwoman

I was searching for visual evidence of the "healthcare not warfare" argument in the U.S. and have found several photos in Flickr. The issue, obviously, is perceived to be one of resources. It's an important debate.

Bullet wound (National Museum of Health and Medicine)

2009-07-20T21:11:00.001-04:00

Bullet wound (National Museum of Health and Medicine)
Originally uploaded by Prof. Jas. Mundie

I was surfing for images about Health and War on Flickr and have come up with some oddities.....

War and Culture: Sarah Trigg and "Santa Susana with Mexican Border"

2009-07-20T21:07:00.002-04:00

Santa Susana with Mexican Border
Originally uploaded by Trigg Studio

I stumbled across the work of Sarah Trigg in an online journal called "Cultural Politics" (URL:http://newsgrist.typepad.com/culturalpolitics/2009/05/sarah-trigg-daily-markings-on-the-face-of-the-earth.html#more) Trigg has produced a series that depicts the lines and traces of war etched on the earth and captured in images. This image is my favorite.

The Undersecretary of Defense for Policy takes on StratComm

2009-07-19T10:27:00.004-04:00

USD Policy has been undergoing significant reorganization lately, and it's shape and function is not exactly clear to those of us on the 'outside'. The Office of the Undersecretary of Defense for Policy is perhaps "The Source" of power within the Pentagon, and the new Undersecretary, Michele Flournoy, is trying to shape her office to be more responsive to the global context, it seems. Those of us around D.C. not within USD(P) are waiting to understand the new organization and it's new direction. The Defense News reported last week (URL:http://www.defensenews.com/story.php?i=4190904&c=AME&s=TOP ) that Flournoy was going to put together a small team to shape communications both to Congress and to other US Govt agencies. The team will replace an office within USD(P) that used to be called "Support to Public Diplomacy". Flournoy disbanded the Support to Public Diplomacy office this year, seeking a fresh start to Strategic Communications efforts after the Support to Public Diplomacy office became embroiled in an internal conflict over it's issuances. (Apparently it was issuing 'propagandistic' information that soldiers in Afghanistan refused to use about casualty rates). While this all sounds rather archaic, it's not. The goal of the team is to coordinate Strategic Communications across DoD. I would suggest they start by reading the CENTCOM reports to Congress on progress in Afghanistan and Iraq. As I've blogged before the reports are pathetic at best, and do not show off the significant efforts in either theater of war.

As the U.S. tries to shape its global presence to positively effect and stabilize the international commons, it must be cognizant of its communications. It's all part of the "Smart Power" construct.

War, H1N1, and Personnel Readiness

2009-07-12T08:40:00.005-04:00

This blog is about DoD's health communications, and the potential utility of a "whole of government response" to assist DoD with H1N1.

As H1N1 makes its way around the globe via public travel, and --troop deployments-- we also are apparently busy in Southern Command delivering protection kits to health care workers in Latin America (Click on the title of this blog for the story from Southcom). I have thought about this particular post for several days now because I am currently in training at a military base. Training at a military base involves heavy 'social' interaction. We eat together, do physical fitness training together, sit in a classroom, huddle around maps for harried planning discussions, congregate over a computer to produce briefing slides for the group, eat together some more, and live in a dorm-like setting. Social distancing is nearly impossible. A trip from my class room to the ladies' bathroom room requires that I touch 3 door handles/doors one way, or a total of six 'fomites' (things that carry germs by being touched repeatedly--like a door knob) for a round trip. While it might seem paranoid that I know this, apparently on this particular base there are verified cases of H1N1. We were told 22 cases when we first arrived. Yesterday, a class mate told me that someone in my class of about 125 students (but not in my particular section of 13 students) had fallen ill and was 'quarantined' to the back of the class. "WHAT?" I asked him. "Yah, the guy had to sit in the back of the class away from everyone-that's what I heard" said my colleague. We were warned, on the first day, that were we to fall ill, we would be quarantined and therefore miss more than the acceptable amount of course work with the end result of being expelled from the the course. Obviously the use of the word quarantine has strayed from its actual meaning.

There are real and potentially unpleasant results should we come down with H1N1. Most of us have been toiling for about a year now, and this is our last phase--to drop out now would be distressing. It might even mean that we would have to start all over because there are limited amounts of upcoming classes, and a limited amount of time to complete the entire course. (Therefore, my heightened sense of concern about the door handles is at least explainable, and perhaps entirely warranted. ) The dire warnings of quarantine therefore produce an incentive to not seek treatment for flu symptoms.

But getting back to the protection kits. While I completely understand the goodwill gesture of distributing protection kits, I am somewhat baffled by the institutional response of DoD. Rumors are starting to circulate about H1N1, with odd descriptions of quarantine and treatment (e.g. treatment with Tamiflu--one of the more dubious rumors) with a predictable amount of resulting confusion. This is how the military works, unfortunately.

So I went surfing through the publicly available DoD information on H1N1 is illuminating--it tells us to wash our hands, cover our nose and mouth when sneezing and stay at home if we get ill. The efficacy of face masks is unproven, therefore not among the recommended actions. Here's the DoD watchboard for H1N1: http://fhp.osd.mil/aiWatchboard/. Although we did receive a 'briefing' about H1N1 that told us that the symptoms of H1N1 are remarkably long lasting, and to cover our nose and mouths when we sneeze, we were not told about where to get more information, and the briefing concluded with the warning about quarantine.

Health communication seems to be the weak point in the DoD's response. While we are generous with our neighbors, I have to wonder if we are appropriately generous with ourselves? Is one website really an appropriate instutional response? Or, a briefing given to an officer with no public health background to present to a packed auditorium of students freshly arrived from disparate parts of the globe? Is this really the best we can do for ourselves? And, is this the appropriate level and style of communication considering the importance of troop readiness? After all, we are in the middle of two wars and troops cannot fight if they are sick. The military health system is stretched thin. Could the Public Health Service be useful here? Where is our "whole of government" response when we are trying to cope with a threat to our own national security right here at home?

While it could be argued that I'm thinking like Chicken Little and fretting over a falling sky, I suspect that our response to this relatively benign flu does not indicate a measured response should a more virulent flu appear this fall.

America's Global Health Influence from the Kaiser Family Foundation

2009-06-16T08:03:00.003-04:00

I was discussing DoD's role in global public health with colleagues yesterday. Most people asking "what is DoD's lane" in global public health are from outside the DoD, and are part of NGOs, IOs, and other USG agencies. The Kaiser Family Foundation and CSIS are addressing the US government's role, and they have some interesting information posted on their website (http://globalhealth.kff.org). They not only have a break down of the monies spent by various agencies, they also have conducted a poll of American opinions about sustaining the substantial investment that the US is making around the globe.

I am beginning to think that the question of DoD's role in global public health is the wrong question, and is really being posed by people from within organizations that have options to either engage or not engage at will. The DoD, unlike other agencies, is not actually free to decide where it will engage, strategically speaking. Of course, at the tactical or programmatic level there are always decisions being made that have some effect. For example, the much-derided 'Medcaps'--somewhere at some level is a DoD employee who decides whether a medcap will be conducting in town X versus town Y. But at the strategic level, the DoD is engaged in Afghanistan and Iraq at the pleasure of our country's politicians. Not at the behest of Secretary Gates. Adding to this perspective of limited choice about the matter is the hierarchical nature of command. All military personnel understand that when the commander (at any level) says jump, everyone jumps. So, when a maneuver commander in Iraq tells his doc to go out and arrange a clinic in the nearby town, the doctor pretty much figures out how to do just that. There's only a very limited amount of free-will in the matter.

It has begun to occur to me that the question of DoD's role, as asked by those from within agencies where people at very low levels are directing programs and making independent decisions, and from within agencies that can decide to be in, say, Iraq, is being asked from the perspective and culture of will. The answer, from a DoD perspective, is that we go where we are told and do what we are told to do in the best way we can figure out. This answer is less than satisfactory to most questioners, and they keep asking.

So, I'm coming to the conclusion that the real discussion should be held at the point of contention: the competition on the ground or in the 'humanitarian space' as it is called. The real question, it seems to me, should be how can we mitigate profound confusion and misalignment of intent? The topic that nobody wants to address is right there: intent. The institutional bias of the Department of Defense will always make the health of other populations a secondary result or interest. In other words, the DoD is actually a health-destroying war-making organization. We know how to fight conflicts. Even in counter-insurgency when the goal is to secure populations and 'win hearts and minds', the DoD's focus will be on security. That's the fundamental nature of the beast. Not making foreign populations healthy. So, how do we create some order and sense of cooperation among the various actors? I think this is the more productive question.

The Long Silence is hereby officially broken: CNAS conference and H1N1

2009-06-13T11:14:00.003-04:00

Haven't had a chance to blog for the past month, but I'm back. So much has gone on, it's hard to know where to start.

First, congratulations to Chris Albon for passing his oral exams, and now being ABD. Chris writes the War and Health blog.

H1N1
Second, the H1N1 epidemic. Guess who exported it to Kuwait via the war in Iraq? We did, apparently. Here's a report from Reuters: (URL http://www.reuters.com/article/healthNews/idUSTRE54M1G720090524)

KUWAIT (Reuters) - Eighteen U.S. soldiers in Kuwait have H1N1 flu, the first cases in the Gulf Arab oil-exporting region, a government official said on Sunday.

"(The soldiers) were confirmed with the virus upon their arrival from their country to the military base (in Kuwait)," Ibrahim al-Abdulhadi told Reuters.

Kuwait is a logistics base for the U.S. army for neighboring Iraq, where the U.S. military said there were no known cases yet of H1N1.

What are the implications of this? Obviously there are diplomatic issues, issues relating to quarantine, sovereignty and the war. Not insignificant.

CNAS

Next, I had the good fortune to attend the Center for New American Security's day-long conference on the counter-insurgency in Iraq and Afghanistan, the problems with North Korea, and a session tossed in about the security implications of natural resources. Kind of an odd mix. The session on natural resources completely bogged down and became dangerously close to sounding like a self-licking-ice-cream-cone argument. Senator Warner moderated the panel and was pleased to describe his previous legislation that demanded that DoD address resource issues in terms of security. The CNAS staffer leading the discussion, Sharon Burke, claimed that it was DoD's responsibility to both fight the nation's wars as well as mitigate potential future wars. (Oh, really? I didn't see that in the Constitution...I'll have to go look again). The panel consisted of two academics and one Navy Commander who is responding to the good Senator's legislation by addressing the security issues relating to resources for the upcoming QDR. Nobody else from DoE or EPA was present apparently. Is DoD really the answer to resource issues? While I don't think it's irrelevant for DoD to be engaged in the discussion, sticking a Navy commander up on the panel with no other USG representative potentially skews the argument. Obviously this problem would require a whole of government approach, but where was the rest of the government?

Quite in contrast to the resource discussion was a panel all about the North Korea problem. The panel consisted of CNAS staff and diplomats with nary a military member present. Really? So, DoD should focus on resources, but not North Korea? I asked about this at the really swell post-conference cocktail party and was told that CNAS had asked for a DoD rep, but the timing was short and none had been proffered. Too bad.

The lunch speaker was the Honorable Judith McHale who gave a terrible speech, reading in a soft voice from her notes, about public diplomacy. It was disappointing to me that when someone from the audience asked about the distinction between Public Diplomacy and Strategic Communications she couldn't answer the question. Oh oh. Obviously she has only been in the position for a couple of weeks, but I would have thought her staff might have briefed her up on what it is that her agency is supposed to do--public diplomacy. I've heard that staffs don't do that in the other governmental agencies.

Look to CNAS to enter the military health/military readiness arena shortly. The basic premise is that if you have a military force with PTSD and TBI and other health issues, readiness is declinated. The 'mavricky' team at CNAS (to borrow a term from the Palin SNL skits) has reached out to an officer who has been severely wounded and become an advocate for soldier's health while remaining in the military. He himself is somewhat mavricky and I look forward to seeing what comes of the effort.

I have much more to post--stay tuned. First I have to write a paper for Command and General Staff College.

President's Global Health Initiative

2009-05-09T12:22:00.003-04:00

The President's Global Health Initiative is resoundingly vague. I see Tommy Thompson in the reference to neglected tropical diseases (really? that's one of our national priorities?), and Joseph Nye and other smart and snappy pol-fashionistas in the reference to smart power. Fortunately the Millenium Development Goals were snuck in there as a nod to gravitas.

You can view the President's statement by clicking on my title, or here's the URL: http://www.whitehouse.gov/the_press_office/Statement-by-the-President-on-Global-Health-Initiative/

DoD has issued several Reports to Congress

2009-05-09T10:52:00.001-04:00

DoD is required to issue reports to Congress about Iraq, Afghanistan and Stability Operations in general.

From the Report on Iraq, it looks as if progress is being made, but not very much--certainly not enough to register in public opinion (available here: http://www.defenselink.mil/pubs/pdfs/Measuring_Stability_and_Security_in_Iraq_March_2009.pdf)

Healthcare
The Ministry of Health (MoH) faces serious human resource challenges across the spectrum of healthcare professionals and ancillary staff. With Iraq’s improved security environment, the MoH has worked diligently to encourage the return of expatriate physicians; the Minister estimates that more than 1,000 physicians returned to Iraq in 2008. To increase skills, the MoH has sent 75 Iraqi medical specialists and subspecialists to various U.S. hospitals and clinics for month-long clinical rotations. Jointly, the MNF-I surgeon and the MoH are finalizing plans to rotate Iraqi healthcare providers through Coalition force hospitals and clinics throughout Iraq. The U.S. Army Corps of Engineers has transitioned 133 new Public Health Clinics to the MoH, although full potential remains limited by poor staffing and the lack of adequate essential services (i.e., electricity, water, and sewage) in some provinces.

Health awareness initiatives and responses to disease outbreaks have been very effective this year, reducing cholera cases by 80%, from 4,700 cases in 2007 to 925 cases in 2008. The MoH is also increasingly able to identify, diagnose, and treat diseases independently. Despite this initial progress, national polling indicates that only 26% of Iraqis are either somewhat or very satisfied with health services, 11 percentage points lower than in November 2007.12

If you go back and read the December version of the same report, the content is basically the same, which makes me wonder about the reporting strategy, and what kind of plan is in place to articulate what is being done vice the objectives.

And here's DoD report on Afghanistan from January 2009: (http://www.defenselink.mil/pubs/OCTOBER_1230_FINAL.pdf) Things are similarly progressing in Afghanistan, though this report does not try to tie the efforts to public opinion, oddly enough. See my other posts on Afghanistan for the similar disconnect between public opinion in Afghanistan and the gains in health care.

Here is the "health" section of the January report: (pg 71)

The ANDS states that by 2010 the Basic Package of Health Services (BPHS) will cover at least 90 percent of the population and maternal mortality will be reduced by 15 percent. Afghanistan has made significant strides in increasing access to basic health care, and reducing overall morbidity and mortality rates. The country has seen improvements in child mortality rates and immunization rates. The MoPH developed the BPHS, a program that includes maternal and newborn health, child health and immunization, public nutrition, communicable diseases, mental health, disability, and supply of essential drugs. In September 2008, 80 percent of the population had access to the BPHS, up from 8 percent in 2001. In summer 2008 USAID and the GIRoA signed an agreement to provide up to $236 million over five years to finance additional health care services in 13 Afghan provinces, with the funds contracted and managed through internal GIRoA processes, for the first time.
Based on this precedent, the European Commission has also elected to now pass its funds through GIRoA-managed processes. In 2007, the Global Alliance for Vaccine and Immunization approved a GIRoA proposal for strengthening the health system, and awarded the Government with $34.1 million dollars between 2007 and December 2011. Current MoPH initiatives include a plan to establish 120 sub-center clinics and 80 mobile health teams. Two sub-center clinics and four mobile health teams were established in June 2008 in Kabul, Parwan, Panjshir and Kapisa
provinces.
Over the next five to seven years, the MoPH will require substantial international
aid; including funding, personnel, mentoring, and assistance; to continue providing the current level of services and to develop a plan to build a self-sustaining health care system in Afghanistan.

There are several important ideas presented in these two reports that are worth monitoring. First, that health is apparently a relatively minor contributor to stability. It seems that health is worth talking about, but not much. It strikes me as odd how much discussion in doctrine and in these reports focuses on economics, but I do not believe that there is a designated specialist in the Armed Forces' officer corps for "economist" (that's militarese for--don't think we have economists running around in uniform.) There is no clear discussion about the relative merit of the various efforts and how they might combine to affect improvements either in popular sentiment or in government capacity.

Another interesting idea here is that DoD has to report to Congress about its goings on, but I wonder what the feedback loop is. If you read the report on Iraq, one of the brilliant successes, apparently, is that the US forces have sent 75 medical specialists to one-month rotations in US hospitals. If I were a member of Congress I would ask if that really is the most notable thing to report, and if so, what strategy are we working on here that we think that sending 75 docs to a one-month rotation was going to make substantial strides in the counter insurgency and the rebuilding of Iraq? Perhaps it is significant, but from a close read I'm not sure I get it. My concern is not so much with the content of the report as it is with the strangeness of reporting. Why report at all?

If DoD has to report to Congress about what it and the other agencies are striving to do, when is Congress and the NSC going to provide clear leadership and signal to the American public and the rest of the USG that we are at war, people are dying on our side and theirs, and a withdrawal is not the simple solution we would wish it to be. Oh wait, that would be hard work, and maybe unpopular work.

USG, DoD, DoS and USAID response to the H1N1 flu

2009-05-03T09:35:00.000-04:00

Here's the U.S. Pandemic Flu page: http://www.pandemicflu.gov/.

Interesting to note that Secretary Clinton, in a preamble to her briefing to Congress, acknowledged the DoS' role in the H1N1 outbreak:http://www.state.gov/secretary/rm/2009a/04/122462.htm .

And, USAID has let lose with $5M: http://www.usaid.gov/press/releases/2009/pr090428.html

Also, DoD has a "Pandemic Influenza Watchboard" available on the web: http://fhp.osd.mil/aiWatchboard/. One of the issues for DoD is personnel managment. Pandemic influenzas could reduce the 'readiness' of military personnel to do their jobs. Obviously this is not currently the issue, but the Military Health System has been diligently preparing rules, guidelines and practices. I wonder if the other agencies have done the same?

Civilian Response Corps

2009-05-03T08:48:00.000-04:00

The Center for Technology and National Security has issued a report called Civilian Surge: Key to Complex Operation. (URL: http://www.ndu.edu/ctnsp/CivSurge_Book.htm). I received an email that summarizes the report well:

Edited by Hans Binnendijk and Patrick M. Cronin, the study recommends what
civilian capacity to build, how much of it is needed, and how to manage and
organize it. Major findings of the book include the following:

* The civilian response capacity force size would best be
served by 5,000 deployable, active-duty government civilians and 10,000
civilian reserves. The cost would be about $2 billion annually.
* The National Security Council's oversight role needs to be
significantly strengthened, the sine qua non of an effective,
whole-of-government approach. A new "cross-functional interagency team"
should be created to coordinate all complex operations.
* The military has adjusted well to the new, complex missions,
but its risks overstretch and needs its civilian partners to build up their
capacity to conduct complex operations.
* The State Department should focus on developing
"stabilization-savvy" diplomats, who should be plugged directly into
"seventh-floor" executive crisis management activities.
* The United States Agency for International Development
should be the operational agency charged with training and equipping
civilians for complex missions. It should be restructured and renamed the
Agency for Development and Reconstruction to reflect its main missions.
* Domestic civilian agencies have skills useful to overseas
complex operations, but special legislation and funding is required to allow
them to participate fully.
* Efforts to educate interagency personnel for complex
operations have stalled and need to be revitalized.
* Overreliance on civilian contractors to fill this need has
led to inadequate government oversight. A new contracting standard is needed
focused on maintaining agency core competencies.
* Homeland security events, such as the response to Hurricane
Katrina, are also complex operations that require collaboration and skill
sets similar to overseas operations. The United States needs to organize in
a way that takes maximum advantage of these synergies.
* Since the US is unlikely to engage in future complex
operations unilaterally, Washington needs to mobilize the civilian capacity
of its friends and allies.
* Connecting with nongovernmental organizations and local
actors is critical, along with maximum sharing of unclassified information
with civilians.

The first part of the report describes (as do most reports like this) a greatly reduced Department of State and USAID when compared to the Vietnam era. And obviously the report ultimately calls for a greatly improved cadre of trained professionals. Interestingly, Secretary Clinton has recently described in testimony before Congress, that the DoS is having trouble finding 500 civilians to go to Afghanistan, and I read in the Washington Post that there is a request before Secretary Gates for military reservists to fill some of the positions, but the reservists would wear civilian clothes and be "low profile" which I assume means unarmed.

I have mixed thoughts about this request, and this direction. First of all, the Army Reserve and Army National Guard have been used fairly heavily in the two conflicts, and are also serving as "backstops" to the active component when the active duty units deploy. Having said that, in reality, a few hundred soldiers is not such a stretch for the entire reserve force (all Services have Reservists), so at least the superficial requirement of finding a body to fill a slot should not be a big deal. What the military has a great deal of trouble doing is finding the right body with the right skills to fill a slot.

The problem for a Reservist (from my perspective) with this plan is that it would do nothing for a military career and in fact could damage it. Much like the civilian world, when a Reservist leaves his 'professional community' people forget who he is, and it becomes much more difficult to describe what he can bring to the table. General Officers are still made from people who followed the very traditional career path of platoon leader, operations officer, executive officer, commander, and so on. So, there is little incentive for the Reservist. At least an Army Reservist (not sure what it's like in the other Services.) Finally, I envision the "low profile" being a partial deterrent to Reservists. From my limited experience, apparently civilians do not have to follow the same force protection rules that the military follows and this might inhibit some from volunteering.

The call to create a civilian response corps has been circulating around D.C. for several years, and the DoS has started to create its own "civilian reserve force". I suspect that it is having trouble incentivizing its employees to join, and this gets back to a refrain often heard in the military: the military is at war, and the rest of the country is not. Were I a civilian living in my pleasant salubrious suburb here in D.C. with a nice comfortable job in the city, why would I want to risk my health, and my life to go to Iraq or Afghanistan? It's a realistic question that the USG must answer. Are we at war, and if so, what is the accountability of the rest of the USG and the rest of the nation for the outcome?

I heard a briefing given by then-retiring Major General Fastabend from the Army's operations division (G3/5/7) who made the point that the military is always accountable. From "winning the war" to protecting service members to protecting Afghan and Iraqi civilians. It's often a life and death accountability. But what about everyone else? I don't think the current administration has answered this question to itself or to the nation.

Swine Flu and Harley Feldbaum's report on US Global Health and National Security Policy

2009-04-29T20:13:00.000-04:00

I am plugging away through the recently posted reports on the CSIS Global Health Policy Center page (see link on right hand bar). The first one up (picked because I am a long-time fan of the author and because of it's attractive slimness) by Harley Feldbaum, Associate Director of the Johns Hopkins SAIS Global Health and Foreign Policy Initiative, is a report on the U.S. policies addressing global health threats. Take the swine flu as a perfect example of what could be considered a "national security" threat.

Harley's report is really interesting though covers a tremendous amount of ground in a very brief period. His basic premise is:

1. That U.S. policymaking is complicated by dependence on health conditions in other countries, and a lack of understanding both domestically and abroad about health issues and their implications;

2. That the U.S. response to infectious disease/bioterrorism has over emphasized defensive medical countermeasures and treatment and under-invested in prevention, strengthening of public health systems and surveillance;

3. That improvements would be an increase in focus on global surveillance and response, attention to the WHO's International Health Regulations, and "putting a high priority on meeting the health needs of developing countries".

Wow. I am especially stunned by the final sentence. What Harley means is not really what the sentence says plucked out of the report like I have done here. Put in context, the essence of the argument is that instead of focusing on specific diseases which threaten the U.S., we would do better to examine the health needs of other countries and identify common ground. In the end making other countries more able to detect and deter disease will only help us. He uses Indonesia as an example--the Indonesian government will no longer participate in the WHO program for bird flu arguing that the U.S.'s program of developing drugs from virus samples donated by poor nations, which then are made available only to wealthy western nations is inequitable.

In theory I'd like to agree that we should place a high priority on meeting the health needs of developing countries. But I'm not sure I do.

For example, at the recent CSIS launch of their commission, there was discussion about chronic disease being one of the biggest looming health threats. Should we focus on assisting other countries with chronic diseases? If not, why not? Should we focus on tropical diseases that are not endemic to the U.S.? Why not? As Harley's report says: "Other major global health problems that do not directly threaten the U.S. population or strategic interests, including negelected tropical diseases, weak health systems, and maternal health, do not share the political spotlight and thus have received little attention or funding." (pg. 11) But, why is that bad? Or, why is that good? It's my tax money, after all. I can make arguments both ways on this sentence.

I think my issue here is that the report is too brief and covers a vast amount of territory. While it's attractive to make uncomplicated arguments, and I admittedly picked his report because it was thin, I am aware of the sweeping language and all the dangers that can attend such language.

The report is really well worth a read, and it touches on the most pressing contemporary problems relating to biosecurity. These are THE problems of today, elegantly presented.

CSIS Launches Commission on Global Health and Smart Power

2009-04-22T07:27:00.000-04:00

I had the opportunity to attend a CSIS launch of their new Commission on Smart Global Health Policy. The idea of the Commission is to create an action plan that will seek ways to create a more strategic approach to the way the U.S. government does "health development" abroad. (Health development in its broadest sense.) (URL: http://www.csis.org/globalhealth/)

As I listened, several things occurred to me. First, that the audience questions tended to focus on the health of recipient populations, or the urgency of need in recipient populations. And therefore one of the underlying assumptions is that U.S. global health policy is intended to make people in other countries healthy. I would suggest that's only one piece of the pie. There are a couple other reasons why we do health development around the globe: 1) because it makes us, the American tax payer, feel good; 2) medicine is a way to engage with the rest of the world that is less ethically challenging than, say, dealing in arms--so it's an engagement strategy; 3) private industry (drug manufacturers) makes money from our efforts to build health systems abroad and has a hand in the development efforts. Those three reasons are just off the top of my head, and need to be articulated better, but I hope they are recognized by the Commission.

Next, there was talk about sustainability. Panelists discussed long-term solutions like creating "systems of delivery" that would endure and help communities for longer than just one intervention. Associated with this thread of discussion was discourse about sustainable funding and I link in the topic of chronic diseases. I thought this was an interesting discussion because there was little clarity (probably due to time constraints) about the taxpayer. The reason some diseases and causes are more popular than others is because Congress pays more out to defend the U.S. from diseases which appear to "threaten" the U.S. in some way. The U.S. taxpayer is not particularly interested in saving rural Chinese populations from obesity, say, whereas the taxpayer might be lots more compelled to take an interest in the next round of influenza.

Finally, the Commission includes a media person. Her focus was unclear to me--she only had a few moments to talk. She presented a view of the media that seemed to focus on their utility as an informational device for the recipient populations (cell phones, popular shows, games etc). I think that's the obvious part of the story and again, what's forgotten here is the U.S. taxpayer. It's obvious to me that the U.S. tax payer does not know what the US is doing abroad in terms of global health, and we do not have a "story line" that the media can tie in to. I think the reason we don't have a developed story line is because America hasn't developed a story and belief about it's good work. That story is what political leaders need to begin to develop in order to influence both U.S. populations as well as foreign populations. It will be a story that the media can help develop and tap in to. Until we do this, "Smart Global Health Power" will be a fractured effort.

DoD Conference on Health Security in Afghanistan

2009-04-21T07:53:00.000-04:00

The Department of Defense is hosting a conference titled Building Health Security in Contemporary Afghanistan which is open to all. Details and registration are here: http://fhp.osd.mil/intlhealth/events.jsp?eventID=7.

The End State--do the ends justify the means?

2009-04-20T07:03:00.000-04:00

I was in Command and General Staff College (which the Army has now mysteriously called "Intermediate Level Education" or ILE...how unromantic) this weekend and we are learning how to write a commander's intent. A commander's intent is how the commander tells his staff what he/she wants to do next, and in general terms, how it's going to get done and what the end looks like. Don't tune out yet, there's a tie-in here.

So, we learned that the commander's intent has three parts-- the purpose of the action-to-be (we are going to charge the hill so we can take that high ground and win the war); key tasks (fix bayonets and on my order charge up hill); and then a description of the end state (the enemy will be destroyed, and we will be hoisting our flag, and the sun will come out, doves will float around). The description of the end state, as it turns out, has three parts, too: a description of friendly forces, a description of the civilian population (where relevant), and importantly a description of the enemy forces.

The instructor had a slide up on the screen and we were glibly moving right through this topic when I suddenly came to the realization that the end state for our conflicts in Afghanistan and Iraq do not match up across the government, I don't think. I brought this up to the class because my colleagues are all talented and come from a variety of backgrounds. The intelligence guy challenged me and thought that the end state is well articulated and clear: obliterate Al Quaeda. Yes, I retorted, but do you think that's the end state envisioned by USAID and the Department of State? And, by the way, is that an appropriate end state? If you read Dave Kilcullen and Gallula others, insurgents don't just get destroyed and disappear as do conventional militaries. They remain active at a very low level for a long time, constrained by civil and international law and police actions, then eventually they peter out. Which end state do you think the Department of State uses? And for that matter, what's the end state that USAID uses? Do they even have an end state articulated?

I keep asking the question if the Department of State and USAID are fighting a counter insurgency of every DoS and USAID employee I meet. Some will argue that they are--USAID, it has been explained to me, is providing some kind of emergency funding as opposed to development funding in Afghanistan, proof of their counter insurgency effort. I remain unconvinced. Although the type of funding certainly is important, I wonder what the vision is for the use of the funds? Humanitarian assistance? Relief of suffering? Is that truly counter insurgency? What if you relieve the suffering of the insurgents themselves? I asked this same question of a civil affairs officer who explained (patiently) that the tasks laid out by the Department of State S/CRS can be matched up to the tasks and lines of effort the military uses. Yes, we can both build clinics, but if I'm building a clinic to co-opt the population and separate it from the bad guy, and USAID is building a clinic so everyone (even the bad guys) can be healthy, we are doing the same thing for two different ends. They might be complimentary actions but then again they might not be. And it seems to me that we need to first of all fight insurgents, and as a second priority make everyone healthy and happy.

If you look at War and Health, Chris posted a blog about humanitarian deaths in Afghanistan (here:http://warandhealth.com/attacks-on-humanitarians-in-afghanistan/#comments) . Off the top of my head I think there were about 150 hostages taken and 40 murders last year. USAID does not use the same force protection posture for its employees, and their "NGOs" are most certainly left to their own judgement. Are they really fighting a war? Do their development efforts measure up to trying to stabilize the population? Or, are their actions creating more instability by creating targets of opportunity? Also, is USAID working with the Minister of Public Health in Afghanistan, say, to target the most influential community members in order to spread approval of the central government's efforts? Or is USAID doing "good work" around the country, developing the health system equally so that "everyone" can receive a health benefit? The two actions might conflict.

I want to be clear that I remain unconvinced one way or another. I simply don't have enough information. I AM convinced, however, that until the entire US government decides to fight a counterinsurgency we will not win. The military cannot win a counter insurgency in a foreign country all by itself. It can only fight the symptoms of the counter insurgency. It's up to the political and developmental sectors to really win. I can only hope they understand this. Otherwise, we will have invested millions and even billions to develop structure for what eventually becomes another oppressive and despotic regime in Iraq and Afghanistan.

Health is a Security Issue.

2009-04-14T06:53:00.000-04:00

The Center for Strategic and International Studies is one of the leading, if not The Leading, think tanks delving in to the health-diplomacy areas. They are initiating a Commission on Smart Global Health Policy which is focused on pushing the USG toward a global health strategy. Here's the announcement: http://www.csis.org/component/option,com_csis_events/task,view/id,2004/.

Intersecting with this, the Obama administration has initiated an interagency policy coordination committee on global health. The first order of business, apparently, is an inventory of which agency is doing what. There is discussion around D.C. about the focus of the US government's energies--on single diseases--and whether there are more appropriate strategies. The Institute of Medicine chimed in on this matter here:http://www.nap.edu/catalog.php?record_id=12506 in it's report to the Obama administration called "The U.S. Commitment to Global Health: Recommendations for the New Administration". The report calls on the President to "highlight health as a pillar of U.S. foreign policy," claiming "It is crucial for the reputation of the United States that the nation live up to its humanitarian responsibilities, despite current pressures on the U.S. economy, and assist low-income countries in safeguarding the health of their poorest members." OK, while this sounds really nice, it seems to be written in complete denial of the 48 million Americans who have no health care. Balancing the priorities of internal and external politics is key to national security. And it's no longer an either-or world. Internal IS external.

The health of our nation has strategic implications. For example, one of the biggest problems facing the Army Reserve component (which means the National Guard and the Army Reserve) is health. The U.S. Army has policies against deploying unhealthy service members. For example, if a service member seems to have a cavity that will become problematic within a year, that service member is considered non-deployable until the tooth is fixed. Because most Americans don't take care of their teeth, guess what the biggest health problem affecting deployments of Army Reserve component is? Right. Dental problems. While not an insignificant problem, I also want to caution that this is not a huge deterrent right now, but more of a useful example. If we don't have healthy Americans to serve in our Armed Forces we have a national security problem. And, so the discourse should be: how much should we spend on making our nation healthy vice making foreign populations healthy? Because first we need to be healthy to work and pay our taxes, defend our nation, promulgate foreign policy.

Where I'm going with this is that reports like the IOM's that place moral and policy imperative on creating healthy international communities should also recognize that we also need a healthy nation. The challenge is not calling for more attention to yet another cause. But calling for a balanced and integrated approach for attending to both a healthy nation as well as a healthy international community. It's easy to pick out a single disease or a couple of causes du jour. It's absolutely not easy to articulate the importance of health to national security internally and externally with a cogent explanation for action. But that, in fact, is what is needed.

Public Diplomacy+Military Medicine=the Comfort

2009-04-05T08:07:00.000-04:00

The intersection of public diplomacy (typically a Department of State activity aimed to influence foreign populations) and military medicine is most easily identifiable in what the Navy is calling Humanitarian and Civic Assistance missions--the Comfort, the Mercy and so on. Under the new Maritime Strategy, the Navy is tackling the problem of how to do medical interventions with a goal of fostering good relations.

The Comfort has just set sail from Norfolk, and here is the blog:http://comfort2009.blogspot.com/.

Twitter, War, and Health

2009-04-04T12:17:00.000-04:00

You MUST NOT miss War and Health's Twitter list. Go here, (do not pass Go enroute): http://warandhealth.com/armed-conflict-public-health-twitter/comment-page-1/#comment-826.

"Mendstate"--and the "end state" problem

2009-04-04T10:56:00.000-04:00

I have been asked why I called this blog "Mendstate". One of the problems of the US effort in Afghanistan and Iraq (and way beyond) is an inability for all the various actors to agree on what the military calls an end state. What are the conditions that, when reached, will define a suitable "end state"? And, in the health sector, what is the role of health/medicine in attaining that end state? (Hence I derived the play on words "mendstate"--mend, end, and state....you get it, I'm sure.)

The Health and Fragile States Network (link on sidebar to right) has a series of documents posted from a Feb 2009 conference on health and security, one of which is a USAID document called "Health Programming in Post-Conflict Fragile States" that I find really fascinating. (Here's where you can find this document posted: http://www.basics.org/documents/Health_Programming_in_Post_Conflict_States_Waldman_Final.pdf) What's so fascinating about this document is the relatively cold way in which the authors delineate the argument that the goal of "health programming" in fragile states is not to make people healthy in the traditional sense. The goal of the programming is to create good governance and good government (which is created via legitimacy... see my earlier posts on legitimacy).

So, the first point the paper makes is that morbidity and mortality in post-conflict or during-conflict states is caused by violence, and therefore programs designed to create "health" (or, reduce morbidity and mortality) should therefore reduce violence:

...if the principal objective is to improve the population’s
health, perhaps disease control programs as they are usually conceived should not be
the health sector’s highest priority, at least in a context where conflict is
occurring or where the likelihood of a return to conflict is appreciable.
Instead, programs that aim to bring about a lasting ceasefire or that
contribute to the consolidation of an ongoing peace process are more
important in the immediate, highly fragile, post-conflict setting. (pg 2)

Nothing new, but a nice clear point to start the discussion.

The next point made is actually a two-fer: 1) that USAID's fragile states' strategy, therefore, is one which seeks to reduce instability by bolstering good governance and governments; and 2) that there is not enough emphasis placed on building civil society as well as governments. To do this there are two objectives, according to the paper, which should be pursued simultaneously: 1) a humanitarian objective of health care delivery, poverty reduction, education and so forth; and 2) political processes which accommodate dissent (this is my way of summarizing the suggestion in the document...it doesn't precisely address this point of accommodating dissent).

In summary, then, the USAID Fragile States Strategy has four priorities: enhance stability; improve security; encourage reform throughout areas of
governance; and develop institutional capacity. The question to be asked
(but not necessarily answered) in this paper is: what is health
programming’s role in addressing these priorities? (pg 3)

The authors then describe the trade offs between building legitimacy (which they suggest might come first, even at the expense of effectiveness, or what I termed 'performance' in my "legitimacy part II" post). Showing good intent, the authors propose, could be more important in developing political stability (and therefore reducing violence with a hoped-for commensurate reduction in morbidity and mortality) than actually putting effective "medical treatment" practices on the ground.

Next they tackle the problem of "equitability" which is a humanitarian assistance mantra that mandates that health care should be delivered equitably between all factions, regardless of race, creed, ethnicity, gender and so forth. Using a rather frank description of the Sudan as an example, the authors discuss how providing health care to the "haves" (vice the "have-nots") can contribute to peace-building and ultimately lower morbidity and mortality, as opposed to direct care to everyone equitably which in some cases may contribute to politically-driven violence, increasing morbidity and mortality.

Then a discussion follows about donor behavior, and the rift between relief and development donations and practices. The conclusion:

...others all suggest that a minimum of $15 per capita per year is required to implement a Basic Package of Health Services. While this amount is
frequently available to fund services provided through emergency and humanitarian assistance mechanisms, it is strangely true that once an emergency is deemed to have subsided, health sector funding is often reduced, while funding is increased to develop other aspects of state functions, such as elections, justice, and other infrastructure areas. It should go without saying that without adequate funding, no form of health sector programming will be successful at bringing about important changes in population health status, nor will the health sector be able to make a significant contribution to improving either the legitimacy of a new government or its effectiveness. (pg9)

And buried a bit earlier in the document, the authors make their point, I think, when they write:

As mentioned above, the focus has been on how to implement the same programs in different circumstances, rather than to look at how the circumstances
might determine the nature and design of the programs. Vaccinating 80 percent
of children is one thing, but achieving high vaccination levels in a way that
explicitly enhances the legitimacy (first) and effectiveness (later) of
government may mean settling for lower levels of achievement, at least in
some areas, paying greater attention to ensuring involvement of diverse
elements of civil society, establishing routine vaccination at local health
clinics, and so forth. Of course, it may also be the case, but hopefully not,
that vaccination programs are not as early a priority as they currently are.
How to make health system rehabilitation contribute to the attainment of
political objectives is challenging and context-specific. Clearly, though,
implanting programs designed for very different
settings is likely to be problematic, and donors need to keep their objectives clearly in mind. (pg 7)

What amazes me about this document is that it just simply ends. I'm not sure that these very important points are fully appreciated, socialized and rationalized throughout USAID, since I don't work there. But they absolutely do fit neatly in with counter insurgency strategy, and my previous questions about whether the rest of the government (USAID and the DoS) are fighting a counter insurgencies or doing business as usual (and sometimes in opposition to the counter insurgency) become slightly more salient suddenly.

I think the principles of development and counter-insurgency can converge at the point of recognizing the political origins (which are culturally derived) of problems and solutions. Here we can find room for debate and discussion as to how to describe objectives and end states, and we need to focus on developing clear thought about effecting change.

The British are getting it right!

2009-04-02T07:04:00.000-04:00

Last month several colleagues of mine traveled to the UK to attend a conference on the UK's role in global health. The British government, it appears, have made significant progress in formulating a "whole of government approach." Presentations and documents can be found here: http://www.chathamhouse.org.uk/research/global_health/.

And, speaking of whole of government approaches....I had the good fortune to attend a conference on Irregular Warfare yesterday at the National Defense University. Although non-attributional, topics of general concern were: a) the inability of the U.S. Government to produce a whole of government approach (the discussed solution was a call for strong Congressional and Presidential mandate, tho there was a lot of sagacious anxiety that this would never come to pass since it appears as if the US as a whole is not really at war) in Afghanistan and Iraq; b) the use of special forces and general purpose forces in irregular warfare (the actual topic of the conference); c) several stabs at definitions of "irregular warfare"/"hybrid war"/"asymmetric war" with a certain amount of discussants thereafter abandoning attempts to be clear about these terms; d) the production of doctrine by the US military and the utility of that doctrine/the role of the doctrine; e) appropriate analysis of context -- a "how to suggestion" by one of the panels-- involving sociology.

It seems to me, from a purely anecdotal perspective, that sociology, anthropology and other previously dismissed "social sciences" are now ALL the vogue, with much side bar discussion about the Human Terrain Teams, their use (it was proposed that the data and knowledge it produces should be used earlier in the cycle of planning), and how to conceptualize "Irregular Warfare" from a sociological perspective. I have been in many meetings where the HTTs are discussed and whether regular intelligence units/agencies (called the G-2 in headquarters units) should incorporate this information rather than have stand-alone cells. These kinds of discussions are important and interesting, because they reflect the military's internal discussion about what needs to be institutionalized.

Then I went to an evening presentation by Dave Kilcullen on counterinsurgency sponsored by the Center for New American Security (URL: http://www.cnas.org/about) . Again, sociology played a role in Kilcullen's thinking, which is not really all that interesting in and of itself, but I was again struck by his calling out of sociological principals. Five years ago most guys in the military would not have cared a lick for sociology. Proof that the military can change is good. Kilcullen spoke in relatively broadly about what to do in Pakistan (as the real problem in Afghanistan), changes in strategy in Iraq and the magnitude of the problem in Iraq.

Charged up with coffee and all these ideas, I'm ready to tackle the world. Off to work!

Pause to reflect

2009-03-30T21:29:00.000-04:00

I forgot to mention, unbelievably, that I saw a report that two US military nurses were in an armed attack in Afghanistan. Unfortunately one has died. I do not have permission to release names ( the families know by now) but am saddened by this report.

While my blog tends to be academic and long-winded, my heart and soul recognizes the human aspects of what we are engaged in. Sinews, bones and blood, tears and sweat. Us, the Iraqis, the Afghans, our coalition partners, and even Hamas, Hezbollah, and what's left of the FARC.

We each strive to create a world of our imagining and in doing so we create a world we cannot imagine.

Legitimacy part II

2009-03-30T19:39:00.001-04:00

I've been away for a couple of weeks, partly due to taking Command and General Staff College on the weekends, and partly because I'm writing a paper for submission to a peer-reviewed journal. The topic of the paper is the topic of tonight's post on Legitimacy, part II.

I've been doing a lot of reading about legitimacy in the political science literature because counterinsurgency doctrine demands legitimizing the established government as a method of opposing the insurgents. Democracy is founded on the idea of 'legitimate' representation. So, I began to wonder what exactly is "legitimacy"?

As it turns out there are several theoretical models of legitimacy which are usually presented in lit reviews, beginning with Max Weber. I'm not going to go through all the models, here, at least not now. The models are useful and intriguing, and describe how legitimacy is essentially a relationship between a population and a government. Legitimacy of the government can be produced via coercion, on the "less legitimate/more unstable" side of the scale, or via consent on the "very legitimate/very stable" side of the scale. So first of all, in a counterinsurgency, we want popular consent--or at least we want the slider on the scale to rest more toward the "consent" side and less toward the "coercion" side. So far so good. Nothing revelatory.

Here's what I found, though, that I think is revelatory. In a journal article from March 1990, "Legitimacy, Religion, and Nationalism in the Middle East" author G. Hossein Razi makes the case that legitimacy is actually a 2-part construct. He doesn't exactly say this--this is my summarization. First, he says there are two basic meanings: 1) that legitimacy means the set of norms and values relating to politics which are sufficiently shared so that a political system becomes possible; and 2) that legitimacy deals with meanings of the purpose of the government, the rights and obligations of the government and the governed and the methods of selection, change and accountability of the government personnel. We normally use legitimacy with the second meaning.

And here comes my 'Ah Ha' moment. The second part of the legitimacy construct is "performance."

Razi says: "...there has been insufficient grasp of the difference between the nature and sources of legitimacy and those of performance (i.e., the production of goods and services and generation of organized instruments of physical compulsion)."(pg 71). He points out that "Success in performance areas... does not necessarily result in an increase in legitimacy....the simultaneous existence of a problem in legitimacy and a problem in performance "characterizes most of the 'crises'" of the Third World...."(pg 72)
(cite:G. Hossein Razi, Legitimacy, Religion , and Nationalism in the Middle East. The American Political Science Review. Vol 84, No. 1, March 1990. pp. 69-91)

To explain what this means in concrete terms: I was recently culling through poll data from the Asia Foundation on Afghanistan (available here:http://www.asiafoundation.org/country/afghanistan/2008-poll.php) . Although the government has performed well in health and education development, and the public recognizes the performance, the overall optimism about the way the country is going is declining. In fact, in spite of recognized gains, the public opinion about the performance of the central government has decreased from 80% positive in 2007 to 67% in 2008. (pg. 53). One would expect performance to be legitimizing by way of producing positive benefit to the people, and the people expressing satisfaction with that benefit. But this apparently not the case in Afghanistan.

It seems to me that a partial explanation is that perhaps the people of Afghanistan do not expect the central government to provide health care. First, there hasn't ever been a real central government for any meaningful stretch of time, and next, no quasi governmental agency ever provided health care. And the fact that the new government does provide health care is nice, but does not change their overall view of the government. It seems from the poll data that economic benefit is expected the most.

A second idea I had was that Afghanistan is a clientelistic political system with patrons collecting resources to dole out to their clients. Because Afghanistan has never had a health system (hence the name "reconstruction" is a fallacy), trading health benefits might not yet be widely perceived to be a useful trading tool. If it becomes a useful trading tool, then there might be commensurate importance placed on government performance in this area.

The problem here is that the use of medicine for counter insurgency and stability operations seems to not be functioning, at least this year. We know so little about legitimacy, that it is hard to posit a time frame for when development activities would actually "legitimize" the government. In fact I suspect that it's probably unique to the culture we are working with. We also don't understand the other variables in the system--I suspect that we don't even know what they are more less their relationships to each other. As with most other important questions of the day, I can say I conclude that "more research is needed."

I read another interesting journal article about health development in Guatemala that sums up everything pretty well, I think:

"Development strategies that attempt to make improvements in the lives of the rural poor without addressing the underlying structural causes of poverty serve to deflect attention away from the real needs of impoverished communities. Though the underlying ideology is that local people should have a voice in solving their own problems, the definitions of the problems and the determination of priorities are usually the prerogative of the outside agencies."

(Cite: Green, Linda Buckley. Consensus and Coercion: Primary Health Care and the Guatemalan State. Medical Anthropology Quarterly, New Series, Vol 3, No. 3, The Political Economy of Primary Health Care in Costa Rica, Guatemala, Nicaragua, and El Salvador (Sept 1989). pp 246-257.)

Who was Thomas Tackaberry? And other (provocative) Counterinsurgency questions

2009-03-18T19:34:00.000-04:00

"Today [1968] the problem of war has dwarfed all others. Science and technology have created a situation which is unique in the history of mankind....In the last 5,500 years there have been 14,531 wars, for an average of 3.18 per year; and in the last twenty years the frequency has increased to 5.2 wars a year. With these statistics, one can safely extrapolate that wars will continue.

Since achievement of the supreme objective of preventing war looks dim, statesmen are fervently pursuing the goal of keeping hostilities at the lowest possible level of intensity.... Since employment of United States military forces in the classical sense is not appropriate, or required, other components of military counterinsurgency must be used. These include psychological operations, unconventional warfare, civic action and military aid, advice, and training. These capabilities have become the primary components of counterinsurgency. Furthermore, successful counterinsurgency is as much dependent on political, social, economic, and psychological factors as upon purely military factors and sometimes more so....

Whether one is concerned with programs to alleviate political, social, or economic sources of discontent [in a counterinsurgency], with techniques of indirect influence, or with the social and political environment in which actions occur, the kind of underlying knowledge required is the understanding and prediction of human behavior at the individual, political, and social group levels....

There has been much discussion about counterinsurgency, but very little directed toward an understanding of the art of insurgency or conspiracy.... Knowledge of how to prevent internal strife is a paramount need. An essential question that must be answered is: What should be the division of effort between repression or conciliation of dissident elements in a prerevolutionary situation? To what extent should one follow a hard or soft line, or a combination of the two, and in what ways and under what conditions...?

The military might of the United States can defeat the military symptoms of insurgency: the big challenge is to insure free, stable nations. In the final analysis, this is a fight for peoples' minds."

~Thomas H. Tackaberry; American Journal of Economics and Sociology; vol 27, No 1. January , 1968. p 1-8 (available on JSTOR). (LTG Thomas Tackaberry received a Distinguished Service Cross for his service in Korea and two more for service in Vietnam. He commanded the XVIII Airborne Corps.)

How is it that this was written 40 years ago and we haven't answered some of the basic questions posed? Tackaberry suggests that the military needed research to answer the basic questions of how people view themselves within their culture, how they decided to become 'revolutionaries', and what the military could do in a counterinsurgency.

I have been thinking about Tackaberry's final assessment that the US military can defeat the "military symptoms" of a counterinsurgency, but that it was going to take a lot more than the military's conventional armament. That's old news that we have recently re-discovered.

I am drawn to consider other options than a purely military response. For example, in this "whole of government" era, where the agencies must seek ways to work together, I am left wondering what is the Department of State's counterinsurgency doctrine or strategy, exactly? And, does the USAID realize that it is joined, whether willingly is another question, to the counterinsurgencies in Iraq and Afghanistan? Or, what about HHS, mentioned in the Iraq SOFA framework~ when DoD withdraws at the end of 2010, what counterinsurgency and stability actions will it take?

While these questions are certainly provocative, they are stimulated by the disturbing fact that LTG Tackaberry asked some of the same ones more than 50 years ago. Although he was interested primarily in providing the military with answers, he also recognized that more than the military was needed as a counterinsurgency response. I am just taking the logic to the appropriate conclusion.

Giving the Department of State more money is certainly a first step. But then we need a real strategy with real priorities. I understand that the DoS is ramping up its staff in Afghanistan and will make a plan. That sounds pretty good: I'm sure the Afghan desk is busy at the DoS and I know the one in DoD is swamped.

But really what I want to know is this: where is the Al Qeada desk?

Down with "Roles and Responsibilities"

2009-03-17T06:53:00.000-04:00

I'll just get it right out: the endless discussions we are having in the government about "roles and responsibilities" of the various agencies are fantasies. I agree with Michele Flournoy in the Armed Forces Journal (In search of harmony: Orchestrating 'The Interagency' for the long war, available here: http://www.armedforcesjournal.com/2006/07/1857934.) She basically says that what we need are a new breed of national security professionals who are "development-diplomats" and "defense-development" experts and so forth (those are my terms, tho), and who are trained at a national security institute--like the National Defense University.

What I would like to see are 'functional' experts who understand global public health across the security domains of defense, development and diplomacy. I'd like to know that the government has a team of experts who sit next to each other and understand how the bad guys are using health as a commodity against the U.S., and what strategies the U.S. is using against them in return. And I'm not just talking about biosecurity either. How about an expert who understands how to reach out to other countries like China in order to partner and do good around the world?

Instead, we seem to be locked in a do-loop of discourse about how the DoD should not be working in the "humanitarian space", for example, because we make the world dangerous. And how USAID's problem is that it can't leave the FOB. And how the Department of State is so weak it couldn't lead its way to the bathroom down the hall. And then the NGO staff stand up at meetings and talk as if ALL NGOs were all working with the same pure motivation and intent, born from a "human rights" perspective that is shared world wide. And the message from all of this is that if only we all knew our roles and responsibilities, and would climb back in to those boxes, then life would be much less frustrating, our actions much more legitimate (see my previous post about legitimacy), and the world an all around better place. And it's the fault of the "other guys" that the world is not 'better' already. Unfortunately, that's just way too easy.

Call me a pragmatist, darn it, but the world is what it is, and what we need is a way to deal with it. A flexible, responsive and initiating way of dealing with it. That is going to take a new breed of national securitists who are sophisticated and smart.

The discourse must change: we need to stop with the "roles and responsibilities". We are all in this together--the "humanitarian space" is populated by NGOs, DoD, USAID, DoS, USDA, private security firms, IGOs and more. It's a cacophony. And there you have it. What we need are good rules for working together, and good processes to at least share knowledge of our often conflicting actions. We must understand that there are differing purposes for being in the humanitarian space, and therefore take different actions. The most reasonable thing we can do is figure out how to best deconflict those actions. It makes sense to have a USG strategy, coordinated across agencies for initiating action and for responding to changes, and "Roles and Responsibilities" is not going to get us there.

The USAID is sponosoring a 90-day assessment in Afghanistan of all USG health development work. I hope it talks about processes, coordination, and methods to at least communicate actions. I look forward to the result.

Health diplomacy explored

2009-03-15T13:52:00.000-04:00

Funny how you run across things on the internet. Here's an important document from the Nuffield Trust about health and foreign policy: http://www.nuffieldtrust.org.uk/ecomm/files/040205Fidler.pdf authored in 2005 by David Fidler.

On Legitimacy

2009-03-15T10:48:00.000-04:00

I was recently reminded of the vitriol between humanitarian NGOs and DoD. The basic argument is that DoD's actions "in the humanitarian space" cause violence, danger to the humanitarian workers and are generally viewed as illegitimate.

This is too easy of an argument to make, and it mires the discussion in the patterns established after WWII where the military does defense, the Dept of State does diplomacy, and where USAID does development and somehow all of those actions are conducted in distinct "lanes". I find this thinking to be old-fashioned and perhaps no longer useful.

I am doing reading about 'legitimacy' in order to understand the word and the practice-implications. My thoughts are very much influenced by Patrick Chabal and Jean-Pascal Daloz's book "Culture Troubles; Politics and the Interpretation of Meaning." (Available on Amazon. com). They posit that culture is a system of meanings, and not of values. By taking this view, they assert that descriptions of culture no longer, therefore would require "an explicit definition, in terms of norms, beliefs and values." (p 23). They quote Geertz "Culture, here, is not cults and customs, but the structures of meaning through which men give shape to their experience; and politics is not coups and constitutions, but one of the principal arenas in which such structures publicly unfold." (p 25).

So, where am I going here? Well, legitimacy of governments is one of the fundamentals of "stability" and therefore a tenet of US National Security Strategy and DoD's counter insurgency doctrine. Ideas of legitimacy are most likely created by cultures as shared meanings and understandings about governance and the relationship between the government and the individual in that culture. So I am looking for an understanding of "legitimacy" of systems outside our own Western view. For example, Afghanistan is a clientelistic society-- what does that mean for governance? What does that mean for the health of their people? I doubt that the people of Afghanistan have the same understanding and ideation of governance as I and my neighbors. Their expectations are different, meaning that development must fit in to their schema, rather than mine. Do the people of Afghanistan expect the central government to supply a health system? I would suspect they do not. We, in America, have the same debate at this very time over the lack of coverage of nearly 50 million people and what should be done. Most people do not expect the government to provide health care to the population. Working with the Minister of Public Health in Afghanistan to build the health system is admirable work, but is it legitimizing the government? Does it de-ligitimize the coalition efforts to be involved? Should only NGOs do this work? All these questions depend upon the cultural ideation of legitimacy and health institutions, I think.

I have not found clear writing on this topic yet, but will keep looking. Meanwhile, there are several thoughts about legitimacy that I read in an essay by Robert Grafstein "The Legitimacy of Political Institutions", Polity, Vol 14, No 1, 1981 p 51-69.

1. "A legitimate regime is more likely to be the stable ceteris paribus than an illegitimate one." (p 51)

2. "Legitimacy, in effect, is a highly efficient way to secure obedience and thus is conducive to stability." (p 51)

3. Legitimacy involves the correspondence "between the overall state of the legitimate political system (for example, stability based on conformity) and the citizens' evaluation of the system (for example, belief in its legitimacy). " (p 57)

4. Compliance is a "necessary feature". (p 57) And compliance involves persuasion on a scale from coercion all the way to appealing to self-interest or tradition.

The essay is primarily focused on Western ways of governance, and discusses liberal democracies, which Afghanistan is not. Nonetheless, I found these few points clarifying. More to follow.

Public Health and Afghanistan

2009-03-02T11:10:00.001-05:00

I was perusing my book shelf for information about the formation of our own Public Health system in order to inform my thoughts about Afghanistan. I have an interesting publication from Pfizer called Milestones in Public Health. Reading through this history of the U.S. Public Health system, I was reminded of the Essential Public Health Functions:

1. Monitor health status to identify community health problems. This would mean that Afgh needs labs. And skilled workers.

2. Diagnose and investigate health problems and health hazards in the community. This means some kind of skilled and mobile health work force.

3. Inform, educate and empower people about health issues. Some kind of communication technique/vehicle.

4. Mobilize community partnerships to identify and solve health problems. Maybe more private sector engagement in Afgh as opposed to NGOs? Don't know.

5. Develop policies and plans that support individual and community health efforts. Two levels of analysis and planning.

6. Enforce laws and regulations that protect health and ensure safety. Hard in de-centralized, tribal territories, but something to keep in mind.

7. Link people to needed personal health services and assure the provision of health care when it is otherwise unavailable. This seems to be the primary focus at the moment.

8. Assure a competent public health and personal healthcare workforce. Goes with first three points and a big problem in Afgh.

9. Evaluate the effectiveness, accessibility, and quality of personal and population-based health services. This point should have gone before point #5 in my mind. But in any case, this would take MoPH resources.

10. Research new insights and innovative solutions to health problems. Same thoughts as for #9.

I like this list because these are what the military calls "lines of effort" and imply tasks like human capacity building. Lab building. Bringing in new partners. It provides a framework for considering how to build a health system, without prescribing the steps.

Afghanistan versus Western Perspective?

2009-02-28T11:42:00.001-05:00

I haven't blogged in a while. My analysis is that the lack of blogging is the simple result of multiple causes: partly because I've caught a mid-winter cold, partly because I've been working to ready myself for an upcoming study on Afghanistan, and partly because I'm in an Army school on the weekends. Today, however, I am going to write down my thoughts about:

Afghanistan.

In spite of the unfortunate confluence of events and the resulting lack of blogging, I have been thinking about the intersection between health, politics and society in Afghanistan, in particular. I will be working on a 90-day USAID sponsored assessment of the US Government's health reconstruction efforts in Afghanistan. This work promises to be informative on a number of levels. I will try to blog about it as appropriate, without giving away the results and getting myself into trouble.

But first, by way of context, it strikes me that there are several fundamental ideas that should be considered in any assessment and framework for the way ahead. Here are some of my initial thoughts, culled from reading and talking with colleagues:

1. Top-down, bottom-up is the best strategy for the way ahead (I stole this from a USIP report on Afghanistan published by Seth Jones and Chris Fair who are both at RAND). Afghanistan has never had a strong central government, and from my reading, the Karzai government's efforts (as would any central government's efforts) are often viewed suspiciously. Therefore, the goal of any health reconstruction efforts must be to promote local and regional ties to the central government and demote the advancement of regional rulers who have further regionalism on their agenda. Not an easy undertaking, but one that apparently USAID and the Special Forces are using now at the provincial level. (For some good reading on this, see Sloan Mann's article on the small wars journal: http://smallwarsjournal.com/documents/79-mann.pdf. Perhaps this approach can be rolled in to a regional strategy.

2. Health care and health attitudes are somewhere pre-civil war US, I'm guessing...tho I'm not a medical historian. Basically, there is no health care system. So, a whole system has to be built. Without a strong central government. This makes me wonder about the viability of the central government's Basic Package of Health Services. The problem here is that the US Government likes to legitimize the central state, because we view the world (and desperately want the world to be) a state-based system. So, we ask the central government what needs to be done. Then we roll up our sleeves and help deliver. Unfortunately, the central government has little control outside Kabul, so this approach is problematic.

3. NGOs provide and have provided most of the care. Therefore, the public probably does not view health care as a legitimate governmental responsibility. It's something that outsiders provide.

4. The Afghan public was recently reported by an ABC poll to have turned away from a positive view of the U.S. Frankly, I'm a bit suspicious about the utility of these polls, but taking the findings in gross, it may be that the US has allied itself too strongly with the Karzai government in the public sentiment. Not sure.

Health people like to think that providing health care makes the US look good in the eyes of the populace. This is a bit naive, I'm afraid. People's sentiments are changeable, though the more stable views are pretty much driven by cultural norms. Hence application of health activities to improve public perception would necessarily have to play along cultural norms. Very tricky. But this supports the argument for bottom-up approaches. If the goal is to be well thought of in order to win the insurgency war, then we need to use current cultural norms (clientelistic, "corrupt" --in our eyes-- patrimonial systems). That implies, by logical extension, that we use health care development in these give-and-take situations to develop some amount of loyalty among the tribal divisions.

5. Everybody is in Afghanistan. (All kinds of nations, that is). Makes things complicated. Afghanistan is not divided up by ethnicity. It's divided by geography, apparently. Local power-leaders rule in geographical areas (valleys). That makes things complex, too.

6. The world economy just tanked, hence the lack of donor contributions should get worse. That means fewer resources. But this is OK, in my mind, since there is no health system, basically. Rather than focusing on hospitals and clinics, perhaps the whole of government effort could be more cheaply focused on hand washing, nutrition and basic sanitation practices. Sometimes fewer resources means more efficient expenditure.

With these points in mind, assessing the construction activities and creating a framework for the way ahead in Afghanistan should be a snap.

Law, Culture and Health

2009-02-17T20:33:00.000-05:00

One of my newest and therefore most cherished hypotheses is that different cultures view governance differently than we do, and cultures also view health services provision differently. The idea that everyone all around the world expects (or SHOULD expect) their government to provide health care is bizarre. One of my subset favorite ideas du jour is that in countries like Afghanistan, where NGOs have been providing health care forever, and where there has never been a strong central government, it doesn't make sense to try to "legitimize" the central government by assisting it with providing health services. However, I'm just formulating this theory, you heard it here first, and I'm sure I'll be back to mull this over quite a bit in the future.

Anyhow, while I was poking around on the web, I came across Georgetown Law's Oneil Institute that has a global public health and law center. Here's the URL: http://www.law.georgetown.edu/oneillinstitute/index.html.

I was thinking about human rights law this weekend (doesn't everyone?), and about war. I have recently read an interesting piece by an Air Force Colonel that described the liberalization of International Law and how that affected war. So, I was thinking about how "the West" also considers war, pondering the idea that cultures also don't think of war the same way we do. It's probably not always an extension of policy by other means, to misquote Clauswitz, in everyone else's mind.

So, where am I going with all this? Well, it seems to me that the Global War on Terror, which is apparently now over somehow...according to the Obama administration...., is being articulated as a war against those who fight against the State-ordered international system. That's kind of a no-brainer, and if you step back, it's a bit startling too. But to move on, it seems to me that rushing hither and thither about the globe helping people develop their own health systems or handing out aspirins in the hope of creating healthy and stable communities might be a bit premature without a better understanding of what THEY think of health, their government and so forth.

I'm speculating, here, really. But it's as fair to speculate in this way as it is to speculate in terms of the benefits of 'health diplomacy' if one were only to focus on benefit to the other guy. Don't forget that there is a lot of gratification in doing good deeds all about.

I have strayed away from my thoughts about law, but they follow along this same vein. Law is the venue by which cultural imperatives express themselves. It would be interesting to study the changes in international health law to better understand international priorities...or at least priorities of the dominant actors in the international arena. Ah ha. Another possibility for a dissertation.

Afghanistan

2009-02-16T16:25:00.000-05:00

Soon I'll be off to Afghanistan to work on a USAID-sponsored assessment of the USG health-sector reconstruction activities. As part of this assessment, my office is also sponsoring a conference on the way ahead in health sector development. I have been coordinating this conference and will post the web announcement and registration page.

Meanwhile, I'm reading up on Afghanistan. Dave Kilkullen recently testified before Congress on "AFPAK" and a shortened version of his testimony can be found on the Small Wars Journal webiste here: http://smallwarsjournal.com/mag/docs-temp/177-kilcullen.pdf.

The interesting thing about all this is the growing (thankfully) recognition that there are geopolitical influences on health. Afghanistan cannot be treated as an entity in and of itself. USAID, apparently, has just sent out an assessment team to understand what can be done in the FATA region. It strikes me that repairing a hospital or training doctors is worthwhile, but probably not really the answer. It seems to me that there has to be structural change to the societies we are working in. And the way to understand this is to ascertain what their expectations and beliefs are. Normally, we do this through the Minister of Health in order to legitimize our actions. The problem with this is that while we gain approval and legitimacy for our actions, we don't understand whether our activities will actually prove viable or not. The normal answer for this problem is to hire NGOs. While NGOs provide part of the answer, I assume, they must be met with healthy skepticism as well since some NGOs are religiously-motivated, for example.

The effort in Afghanistan will continue to take time and patience. The American people will have to be reminded of 9/11 many times in the near future, I suspect. But as Kilkullen points out, there is no way to take short cuts here. Let's hope Charlie Wilson's War made its point.

Trying to find an interagency solution

2009-02-02T21:13:00.000-05:00

In the newly released Quadrennial Roles and Responsibilities document, Walter Pincus from the Washington Post reports that DoD wants various USG agencies to share goals, budgets and understandings of the end state. Imagine that. Coming from DoD.

Here's the Pincus rundown: http://www.washingtonpost.com/wp-dyn/content/article/2009/02/01/AR2009020101964.html.

There are sooo many opportunities to leverage existing operations for institutionalizing practices. It nearly makes me want to cry.

"Health Diplomacy"--What is it? The NIC report "Strategic Implications of Global Health"

2009-02-01T16:12:00.001-05:00

I went to an interesting round table last week and listened to a brief discussion about "health diplomacy" among other things. Most of the other people at the table were from DoD, State,NGOs and various academic-types. It was proposed that we take up the theme of "health diplomacy" at the next round table. Almost somehow in concert with this proposal, I see that the Chinese have revved up their hospital ship and are making some news. In fact, they even receive an honorable mention in the National Intelligence Council's assessment "Strategic Implications of Global Health" found here: http://www.dni.gov/nic/PDF_GIF_otherprod/ICA_Global_Health_2008.pdf.

Like most scary phrases, "health diplomacy" probably means something completely different to a DoD-person as compared to a USAID person, for example. And I wonder what an NGO person would think? The U.S. military's Mercy and Comfort ships are usually cited as "health diplomacy", whereas efforts in Iraq and Afghanistan and the Horn of Africa or even the Ukraine are not mentioned. While I'm not quibbling with the use of examples, I'm not comfortable letting it rest at merely the Mercy and the Comfort.

Although while "health diplomacy" is not defined in the NIC report, it is interesting to note that on page 7 of the report, the NIC assessment suggests that "More and better-publicized developed world medical diplomacy efforts -- for example, the U.S. Naval Ship Comfort's humanitarian tour of 12 Latin American countries in 2007 could mitigate such influence [of Cuba and Venezuela] while improving the health of citizens of poor countries. "

Using health as a commodity with which the U.S. (or other nations like Cuba, or even organizations with agendas like NGOs) can influence the world is not new. Much like Russia uses oil and the pipeline through the Caucasus as a commodity for manipulating the international order, the West is using health. I'm not sure that I have heard this discussed, since most of the people talking about the diplomacy-development and defense "health" triad are health people who really only want to make others happy and healthy members of the world. However there are some ethical implications, clearly, as well as "execution" and outcome implications. If the Mercy and the Comfort are merely symbols of the US' goodwill, for example, then I wonder if it would be better just to sail around with a bunch of pop stars--Britanny Spears and Bono maybe--making port calls giving free concers. Might be cheaper, and a better use of talent. Probably less ethically challenging anyhow.

In any case, "health diplomacy" is a topic of discussion in the NIC report, in spite of the lack of definition, or any evidence that using health as a diplomatic instrument is useful. But that's OK, it starts us all talking.

Strategic Communications Post-Conflict

2009-01-27T11:52:00.000-05:00

I read an interesting document by Frances Fortune and Oscar Bloh called "Strategic Communication: The Heart of Post-Conflict Processes" published in Conflict Trends. I can't figure out where the source document is, but I received it via my subscription to the Human Security Gateway, which I highly recommend. The Human Security Gateway can be found here:http://www.humansecuritygateway.info/ and has LOTS of great resources.

The interesting thing about this piece is that the authors posit that if done well, a post-conflict government's communications can: a) manage citizen's expectations; b) engender ownership; c)promote inclusivity; d) strengthen transparency; e) improve credibility and confidence, and so forth. I think these are rose-colored-glasses statements. No doubt good communication is "good" on a binary scale of good and bad, and will enable citizens to understand their government. However the article starts off with this statement, which gives definition to "goodness" : "The overriding objective of any strategic communication is to engender change: a shift in citizens' attitudes (their perceptions) and behaviors (their actions) toward development and governance processes and how they own it." This statement elevates "strategic communication" into the mind-bending realm rather unrealistically.

The U.S. military is all wrapped around the information/communications pole similarly. And nobody seems to be reading the more than 30-years of literature on mass communications and its effect on populations' perceptions and behaviors. We know, for example, that there are very few mass media techniques that can change public behavior. We know that individuals can decide to change their behavior and can articulate the psychological stages that lead up to those changes. We also know what obstacles people face when trying to change their behavior and ways around those obstacles (thanks to Bandura, among others). Hence the idea that mass communication can change attitudes and perception as well as behaviors is very optimistic indeed. In fact, it's way over stated.

Course in Geneva on Health Diplomacy

2009-01-19T17:02:00.003-05:00

While searching the web for PhD programs of interest, I came across an announcement from the Graduate Institute of International and Development Studies in Geneva for a one-week course in Health Development. It's only about $2500 for the week, not including airfare or room and board.

Here's the announcement: http://graduateinstitute.ch/executive/global-health-diplomacy.html!

See you there...

Defense, Diplomacy and Development: A Gordian Knot?

2009-01-18T11:25:00.000-05:00

CSIS issued an interesting report a year ago which I just finished reading this morning called "Integrating 21st Century Development and Security Assistance; Final Report of the Task Force on Nontraditional Security Assistance." The report can be downloaded here: http://www.csis.org/index.php?option=com_csis_pubs&task=view&id=4236. I liked the thoughtful writing and thought that the report provided insight into the diplomacy-defense-development nexus which is quite a Gordian Knot for practitioners and for the various involved agencies. I will write more about this report later, since it caused me to more clearly consider the legitimacy of the NGO claims against DoD--and in my mind pointed out why DoD may be somewhat unresponsive as a bureaucracy to those claims. But that controversial post is for the future.

I was also reading a report from October 2008 called "Health System Reconstruction: Can it Contribute to State-Building?" The report was commissioned by the Health and Fragile States Network and can be downloaded here: http://www.healthandfragilestates.org/. In it, the authors investigate, with a clarity that I have not see before, the argument that development of health systems creates a more resilient state. They define "resilient state" by these characteristics: a state with organizational and institutional capacity (to make and enforce policies, ensure the implementation of state-sponsored programmes, etc.); with legitimacy; with political processes to manage expectations (the compact between state and its citizens); and with access to resources. I think defining these characteristics further clarifies the argument heard over and over again that "health diplomacy" is probably a good thing for the U.S. to do, especially in the context of the Global War on Terror, since it builds legitimacy of foreign governments. The authors of the report conclude that this argument, that building health systems in fragile states will legitimize the state (and the successor argument that we should therefore assist with health system development because legitimizing states will mitigate development of terror networks and reduce potential for attacks against the U.S.) is unsubstantiated at this point. I'm not surprised.

Further, I actually wonder if building health systems in fragile states (whether being done by the U.S. government, U.S. military or NGOs or all three) might be a stimulus for Islamic terrorist groups? I know, this is heresy, but my general train of thought is this: Islamist terrorists are waging a war that is based on profound and inarguable religious beliefs. They believe the West is wrong, generally put. We (the West, or America) come in to their communities and try to assist their opponent governments, which are very weak, with building health systems so that the government may be responsive to its divided people. The first problem with this scenario in my mind is that not everyone all around the world expects their government to provide health care services or systems (so that others -- like NGOs -- can deliver the care). So trying to get a government to establish a system might not be enabling the Citizen-State relationship that we in the West prefer to see. In other words, our actions are never going to produce the results we hope to see. In fact,we might actually be disrupting the expected governance structures which might be based less on central state governments or on governments at all, but be based on 'war lords' or local strong men. Could it be that we sometimes are stimulating further disruption by our "good deeds"?

Assuming that we feel it somehow a basic and shared human value (Condoleeza Rice has said something to this effect) that all people should get health care everywhere and that by extension, we should try to work toward that end, we must act with caution since apparently there is no recognizably effective method of acting. The Western world often feels that it has a moral imperative to assist with saving lives where ever and whenever it can. But does that life saved cause another life lost elsewhere?

I am not a proponent of endless navel-gazing while these important issues are pondered by wise men with long beards. But I am a proponent for action which is documented and which can therefore be considered and assessed with some clarity for 'course correction' in further actions. The Health and Fragile States Network report should send a chill through the Gordian Knot of U.S. diplomacy, development and defense communities which are now engaged in trying to be more effective, as evidenced by the CSIS report. But it probably won't.

Militarizing health? Or "health-erizing" the military?

2009-01-16T06:57:00.000-05:00

Well, I had my first comment on this blog, and it was smart and well appreciated! I even liked the teaser sentence: "addressing the Maslowian Hierarchy of Needs via legitimate organs of the Westphalian State, rather than create opportunities for the emergence of illegitimate power structures". Wow, who wouldn't be intrigued? I have often thought about, and at one point invested a bit of time toward a lit review on, Maslow's Heirarchy of Needs as it applies to the application of "smart power". The Army teaches us the PMESII model of assessing the current operational environment (Political, Military, Economic, Social, Infrastructure and Information). We invest huge amounts of energy and money to build economies and teach others how to have legitimate governments. Obviously these are important. But you can't go to work in your new government job and then spend your salary buying dinner if you are sick. And you'll notice that Maslow's Heirarchy of Needs is buried in the "S" portion of the analysis...deeply buried. I'd like to do an analysis that would describe the cost-benefits of public health system building vice building other governance structures. And obviously in practice it's not an either or situation, but it might be a worthwhile consideration that would modify our practices. What to do first and what sector should be focused on? Seems likely that first we would start with Maslow's Heirarchy of Needs and then over time shift focus or expand focus to other sectors. But maybe not. And, separately, I wonder if burying "health" in such an ambitious analysis describes what the military thinks of health care?

Now, on to today's topic, which is not unrelated. I was reading Defense Secretary Gates' transcript in the Jan-Feb 2008 issue of Military Review called "Beyond Guns and Steel:Reviving the Nonmilitary Instruments of American Power". This transcript was of a speech Secretary Gates delivered in November 2007. The speech is worth a read and has been languishing in a deep pile on my desk for a while, obviously. Secretary Gates discusses the need to invest in the foreign diplomatic efforts of the government. In it, he describes the military's use of anthropologists. Anthropologists are now being hired by the military to help describe and "translate" important cultural aspects of tribes in Iraq and Afghanistan, for example. (Their work is reaching more broadly than this, but this gives an idea). The professional field of anthropology has reacted very negatively to this trend, labeling the woman who is the primary proponent of this activity and saying that she is "militarizing anthropology". In his speech, Secretary Gates says that an unnamed person's response to this accusation is "...we're really anthropologizing the military." Ahhhh!! I like that.

In the same vein, the debate about DoD's role within the US Government's global public health engagement has a side-discussion that says that DoD is "militarizing public health". Global public health practitioners are all a twitter. Those that despise the military for whatever reason can repeat this mantra as some kind of justification for not working together.

DoD has been engaged in public health works around the world for.... at least decades (good topic for another post). To think that DoD will suddenly stop engaging in the world via delivery of health services is counter-factual and a denial of history. However the role that DoD plays can be shaped, and that's where I liked the idea of "health-erizing the military." In other words, perhaps its time that the other agencies help DoD understand that it has a talent. That helping peoples in other lands develop their public health systems might sometimes be an appropriate use of DoD resources, and an activity that will create healthier populations abroad and at home, legitimize governments, boost economies and hopefully give a good impression of America. It's not an either-or world: that there is still enough world for both USAID and DoD and the Dept of State to do good. Instead of complaining, why not grab the bull by the horns and give it a little shake? I can only hope that the incoming political appointees will reach out and grab ahold.

GAO's 13 Priority Items for the New Administration

2009-01-12T07:13:00.000-05:00

The Washington Post has picked up on a webpage posted by the GAO that apparently is designed to influence and inform the incoming administration about what it considers the top 13 items of concern. (As an aside, one of the top thirteen problems is the conversion to digital TV. Amazing that television technology is equal to defense problems.) The GAO page can be found here: http://www.gao.gov/transition_2009/.

Six of the thirteen items deal with defense issues, and four of the thirteen related to health, the military, and the military health system's efforts in global public health :

-Preparing for a public health emergency
-U.S. efforts in Iraq and Afghanistan
-Undisciplined defense spending
-Improving U.S. image abroad

I suspect that the GAO reports that support each of these topic areas do not link or even discuss the military's global surveillance efforts and the effect that it has on preparing the U.S. public for a health emergency (or on the military's energetic efforts in pandemic influenza preparations), for example. But in all honesty I need to read the reports to be sure.

What I do know is the confusion of the post writer in today's paper when he broadly linked DoD's strategic communications efforts and information operations efforts in Iraq with public diplomacy. Here is Walter Pincus' article: http://www.washingtonpost.com/wp-dyn/content/article/2009/01/11/AR2009011102122.html?nav=emailpage.

Not to dive in to the unending debate about the difference between strategic communications, public diplomacy and information operations, the point here is that DoD has purposes which tend more toward fighting wars than making people love the U.S. The significance of this is important because the techniques used, money spent and outcomes produced are not the same for DoD as for, say, the Department of State.

Similarly, sometimes when DoD medical personnel perform health missions abroad they are doing so to 'win the war' and not necessarily to better the health of the people they interact with. In fact, I would suggest that most of DoD global health missions are conducted for reasons other than promoting healthy populations abroad. While this seems ethically challenged, the good thing is that in fact the secondary output of these missions is that people receive medical attention. Whether or not their health improves is another question all together. Practitioners from the US AID shudder with this kind of thinking, but in the same breath will say that they are doubtful about DoD's role in global public health.

This same point can be made regarding public diplomacy. DoD has the responsibility to support the development of Iraq and Afghanistan, in concert with other agencies and organizations. The SOFA agreement withdraws all combat forces by June of this year and the entire military by the end of 2011. The Department of State and USAID can remain in country. Just these time lines alone dictate different possible approaches.

Subtleties of purpose are causing great consternation in practice between the agencies. Congressional misunderstanding does not help. Recently, Congress asked the DoD to stop spending so much money on strategic communications in a number of areas. Is the Department of State going to take up the important work in Iraq and Afghanistan, and integrate military missions with messages? Hopefully not. Hence, when Walter Pincus links public diplomacy and DoD's information operations/strategic communications together the danger is that Hill staffers will not understand the important distinctions and add to the challenges of succeeding in Afghanistan and Iraq.

Unified Command Plan

2009-01-10T12:53:00.000-05:00

The new Unified Command Plan was released recently, realigning responsibility for several nations, and more importantly, prioritizing stability, security and reconstruction operations (SSTRO) along with pandemic influenza.

First the pandemic influenza news is interesting because responsibility was given to NORTHCOM, the command that has responsibility for the U.S. area of operations. While the apparent intent of this move was to deliver this topic to one single agency for oversight, the discontinuity between the operational agencies of the military and the policy agencies may widen. Currently, the Assistant Secretary of Defense for Health Affairs (ASD(HA)) has responsibilities for surveillance operations. And, while not a Mars-Venus situation, NORTHCOM is miles away from D.C. both geographically and somewhat less, but not insignificantly, culturally. Pandemic Influenza response initiatives are wide and deep across the federal agencies, and it will be interesting to see how this apparent shift in responsibilities pans out.

Second, the prioritization of SSTR operations is interesting news. The reason for prioritizing stability operations (as they are called for short) is that the U.S. policy crowd would like to mitigate future conflict before it happens, and not always by application of the Bush doctrine. They would like the military to conduct operations that will create/support capable and legitimate governments. However, the use of the military for pre-conflict stability operations is an imaginative leap into an abyss for many in the military. With little evidence that using the military in this way actually creates any stability at all, other than hopeful anecdotes heard in conferences all across the land (validated by wonderful heart-warming photos of smiling children in dirty clothes and raggedy hair), the fighting force is asking the question--what are the priorities and where? The answer men, supposedly in the Department of State and U.S. AID, seem to be unhelpfully commenting in the media about what a bully DoD is for sucking up all the tax dollars, and not really stepping out with comprehensive and rationalized plans across any region at all. Aside from sniping at DoD, there also is much news from the Department of State about the Civilian Response Corps, which is supposedly a reserve force of willing and able civil servants who will march across the foreign lands (doing what?) in support of foreign programs. In other words, it seems as if there is a huge disconnect between the policy makers and the policy-executors, which is really nothing new.

This leads me to Afghanistan. The time is ripe for a broader prescription for what ails us in Afghanistan, but I have heard nothing from any quarter. The U.S. is engaged in two operations there: International Security Assistance Forces (ISAF), and Operation Enduring Freedom (OEF). The legal mandates for both do not allow expansive engagement with the multitudes working across the country. Instead we are restricted to building Afghanistan's own security forces, primarily. This is leading toward ineffective and piecemeal projects. Progress is slow. Painful. Yet where is the State Department? We need a comprehensive plan, with public diplomacy as a key driver. Keeping these two goals in mind, a plan must soon be articulated across the agencies so that the policy will finally connect with the execution. And even if the effort is messy, which is necessarily will be, we will finally at long last have taken the next step in this idea of stability operations.

Must-read: presentation by HHS Secretary Leavitt on Health Diplomacy

2008-12-27T11:43:00.000-05:00

On December 12, HHS Secretary Michael Leavitt gave a really terrific presentation on the importance of health diplomacy for the CSIS speakers series (http://www.globalhealth.gov/news/news/121208b.html). His discussion was one of the best that I have considered recently. I recently put on a symposium for the Asst Secretary of Defense for Health Affairs called Culture, Health and Human Security where Dr. Steve Morrison spoke about the DoD's role in foreign policy. He too made similarly powerful points. (I'm struggling to get a web page up with the video of the presentation, but will post a link once I'm successful.) They seem to share a similar vision about the nature of health diplomacy, the challenges and the solutions. I'm glad to read such sophisticated and interesting analysis and wish it were wide-spread.

One of the more important points, to my mind, that Secretary Leavitt made was this:

Health is a legitimizer of governments and of
ideologies....(p. 13) The fact is in many regions of the world, democracies
are in a test-drive status, if you will. Healthcare is a
litmus test for these governments on whether they are
legitimate and whether they are affective. Using healthcare to
discredit democracy and the ideologies of liberty is a tactic
that is right out of the insurrectionist’s handbook. (p.15)

Secretary Leavitt describes how Castro exports poorly-trained doctors all over the world to under-served areas. The doctors fill a void (tho perhaps not very well) for medical services, and as an added bonus assist with political agitation. Castro makes money off the exportation of these doctors which furthers his ability to create more. According to Secretary Leavitt, Hugo Chavez is starting the same model.

In Central America, I believe we’re at some risk of
seeing 30 years of progress toward democracy erode. In country
after country in Latin America, leftist governments are being
elected. Healthcare is being used by their left-leaning
candidates to stir up discontentment among the people.
The first time I met Hugo Chavez, he said to me, “So,
what is the infant mortality rate there in Washington D.C.? In
Cuba, he said, it’s about six out of 1,000.” Now, I have no
idea whether what he said about Cuba is accurate, neither does
he. But the fact that he used Washington D.C. where it’s a
little higher around the rest of the United States demonstrated
to me that he was using this simply as a means of comparing
their capacity as a socialist government with ours as a
democracy. (p. 15)

Secretary Leavitt addressed the concerns of some who feel that health should not be mired in self-interested policy equations of the federal government. He explains (as did Dr. Steve Morrison from CSIS in his introduction) that the world is smaller now and the health of everyone is our business because illness knows no borders, and because health services can be used by governments:

This isn’t just about getting our approval ratings up.
This is about benefiting from our benevolence. A few weeks
later, I read in the paper about American and NATO troops
entering Pakistan territory, seeking to root out a high-profile
Al Qaeda leader who had been hiding in their mountains. It was
a necessary use of hard power, one that would ultimately and
obviously created a sense of controversy among our critics in
Pakistan. I’m guessing the reaction in the earthquake area
wasn’t quite as quick or quite as severe. This is what Bob
Gates has been talking about. It’s the integration of our hard
power and our soft power, benevolence and benefit. (p 22)

He hits the nail on the head when he describes the abysmal job the federal agencies and other U.S. organizations do 'branding' themselves:

The most significant deficiency in U.S. government
foreign assistance delivery is the rather abysmal job that we
do in branding ourselves and our activities.
This is not only true of health alone. It’s true
across the board. Every agency of the federal government has
its own focus and jealously guards its own turf. Often there
are contests that have to be resolved by putting all of the
participating agencies are having their seals and their symbols
on the same material. Many of you who work in the
international arena have seen this.
Routinely, one can see printed material with up to six
different logos from six different departments or agencies of
the federal government. (p 24)

And, as if in response to my previous blogs he makes the point that the federal agencies must work together, and that fixing one agency (e.g. USAID) is not going to cut the mustard:

This is not a trivial matter. The way our government
does not optimize the benefit of our benevolence is something
we need to change. Fixing the federal government’s siloed
approach, however, can only be done by the President. Fixing
it one department at a time won’t work. The next president
early on should implement a common branding strategy across the
government by executive order.(p26)

Wow!!

"Can Washington Get Development Right?" another DoD smackdown?

2008-12-26T12:16:00.000-05:00

More food for my (f)ire about the political maneuverings here in DC between the Dept of State, and USAID.

Foreign Affairs has an interesting piece by J. Brian Atwood, M. Peter McPherson and Andrew Natsios called "Can Washington Get Development Right?" in the November/December 2008 edition (http://www.foreignaffairs.org/20081001faessay87609/j-brian-atwood-m-peter-mcpherson-andrew-natsios/arrested-development.html). In it, the authors make a couple of strange statements:

...democracy-promotion programs and the Defense Department's aid programs around the world should largely return to civilian control, with the relevant authority and resources assigned to the new USAID. (pg 131)

DoD's aid programs? What aid programs, I wonder? Perhaps they are referring to DOD's mil-mil programs? Or how about the Overseas Humanitarian Disaster and Civic Assistance program? The OHDACA program is very small. Not even worth mentioning in an article about reforms that USAID needs published in Foreign Affairs.

Another odd statement:

Of course there will be areas of overlapping jurisdiction between the defense, diplomatic, and development institutions. One example is the provision of security assistance in countries recovering from conflict; in these difficult environments, the State Department's diplomatic mission is crucial and the Defense Department is needed for training and logistics. The key is who controls the money for noncombat activities. This authority belongs with the diplomatic mission. (p 132)

Huh? The Defense Department is needed for training and logistics, and not economic capacity building or providing security itself (vice "providing security assistance" used by the authors)? I wonder if the article was edited so dramatically that a portion of this paragraph was edited? It is so unbelievably simplistic that...well, it's unbelievable. The discussion of "combat" versus "noncombat" is difficult in post-conflict reconstruction settings. Bureaucracies must work hand in hand in this setting. The authors' maybe make a mistake in their brevity: trying to line up responsibilities in the manner suggested is simply not realistic. When military personnel are setting up clinics to treat local nationals, that is neither logistics nor training. Nor is it "combat" per se. So, how would these type of missions fall in the minds of Messrs. Atwood, McPherson and Natsios? I have a quibble with important people making simplistic little statements like this in important journals like Foreign Affairs.

The reason for my dismay is the same as in an earlier post. I think the "roles and responsibilities" question is being played too hard during this change-of-administration period to make the case for the Dept of State and USAID. It's time for serious thinkers to tell both the American public as well as the administration (both incoming and outgoing) that all agencies within the government have to work together. Roles and responsibilities are never going to be delineated in advance for all contexts. Nonetheless, the Dept of State and USAID must be enhanced in human and fiscal resources so they can work with other agencies, like the DoD. It's not "us" against "them". DoD is not hoarding all kinds of aid money, since it doesn't perceive itself to be an aid agency. DoD fights wars, first and foremost, and it also does stability, security, transition and reconstruction operations, just like always. Strong partners will make DoD's efforts more likely to end in success. I cannot say it more eloquently than Secretary Gates, writing in the current Foreign Affairs issue (http://www.foreignaffairs.org/20090101faessay88103-p0/robert-m-gates/a-balanced-strategy.html):

What is dubbed the war on terror is, in grim reality, a prolonged, worldwide irregular campaign -- a struggle between the forces of violent extremism and those of moderation. Direct military force will continue to play a role in the long-term effort against terrorists and other extremists. But over the long term, the United States cannot kill or capture its way to victory. Where possible, what the military calls kinetic operations should be subordinated to measures aimed at promoting better governance, economic programs that spur development, and efforts to address the grievances among the discontented, from whom the terrorists recruit. It will take the patient accumulation of quiet successes over a long time to discredit and defeat extremist movements and their ideologies.

Gates' whole article is worth a read. And, on that note, there is an interesting editorial in today's Washington Post about USAID. The thrust of the editorial is that USAID personnel in Afghanistan are rendered ineffective by their inability to leave the security of their compounds.

Senator Hilary Clinton and the State Department

2008-12-24T07:44:00.000-05:00

Senator Hilary Clinton has been making news about how she plans to shape up the Department of State. According to reports in the New York Times (http://www.nytimes.com/2008/12/23/us/politics/23diplo.html?_r=1&hp), she plans to seek more money for the diplomatic corps. The military, according to the report, is delighted :

For years, some Pentagon officials have complained that jobs like the economic reconstruction in Afghanistan and Iraq have been added to the military’s burden when they could have been handled by a robust Foreign Service.
“The Pentagon would like to turn functionality over to civilian resources, but the resources are not there,” the official said. “We’re looking to have a State Department that has what it needs.”

And apparently, some of the blame for the current problem seems to lie with former Pentagon resident, Colin Powell, Dick Cheney, and even "the intelligence agencies" :

The steps seem intended to strengthen the role of diplomacy after a long stretch, particularly under Secretary of State Colin L. Powell, in which the Pentagon, the vice president’s office and even the intelligence agencies held considerable sway over American foreign policy.

In their search for a story--" the blame," --the important point that the authors miss is that it will take more than one single agency in this complex world to solve problems. The Pentagon will most likely be involved in economic reconstruction somewhere in the world at any given point, regardless of what the Treasury or State Departments are doing because the economy in question is embroiled in some kind of armed conflict. Under NSPD-44 the Dept of State has the lead, and of course it therefore needs to have more resources, for responses to complex emergencies. But the newsworthy point here is that all agencies will work together as we go forward. The media could help shape the public and political understanding were they able to better describe this sea change.

Happy Holidays!

"A Gentler Hegemony" the way forward for the US military?

2008-12-17T07:49:00.000-05:00

Robert Kaplan published a provocative editorial in the Washington Post today (http://www.washingtonpost.com/wp-dyn/content/article/2008/12/16/AR2008121602480.html?nav=hcmoduletmv). He opines that the future role for the military will most certainly involve responding to humanitarian disasters like tsunamis and earthquakes with assistance. In fact he posits that international community will demand that the U.S. military be responsive:

"American military power is not going away. But instead of being in-your-face, it will lurk just over the horizon. And that will make all the difference. " He goes on to say: "As world population rises, and with vast urban areas with tottering infrastructures in the most environmentally and seismically fragile zones, the opportunities for U.S. military-led disaster relief will be legion. The American military remains a force for good, a fact that will become self-evident in the crises to come." However, "Yet American hegemony post-Iraq will be as changed as Britain's was after the Indian Mutiny. It will be a more benign and temperate version of what transpired in recent years. Henceforth, we will shape coalitions rather than act on our own." Kaplan's thoughts are framed by his view of America's decline, and here I am plucking out pieces that relate to the military.

Kaplan's linking of America's decline to the use of the military is perhaps the most provocative thought, among many other provocative thoughts, of this editorial. The military's view is that there is more than one instrument of national power. However recently it has become more than obvious that the military is the most-used, or at least the most-funded and therefore most robust instrument. Regardless of whether America's hegemony is waxing, waning or plateauing, could it be that more use of public diplomacy, the State Department and USAID will better legitimize the actions of the U.S. in the international public view?

Although Kaplan most likely hits the nail on the head that international opinion will cry out for the U.S. military to respond to humanitarian disasters, what he doesn't address is the next logical question: Is it ethically, politically and logically appropriate for the U.S. military to get in to the humanitarian response business when there are many many other more experienced players? Maybe that's actually three questions, but three inter-related questions.

Perhaps the role of the U.S. military is better abridged to fighting wars? By rushing to comply with international opinion, do we lose legitimacy with the publics that we are trying to aid? Not every public is happy to be rescued by Americans or even people in uniform. Think of people who have been living in conflict zones for their whole lives--trust in a uniform might be lower than we expect. As we should have learned in Iraq, the rest of the world does not share our world view.

Further, could it be, as some argue using what ethicists call a distributive justice argument, that by using military capabilities to rescue other peoples we are taking away from our own?

These are important questions that we need to answer, and that we most likely will begin to answer, by trial and error.

The role of information and health in the GWOT

2008-12-09T06:37:00.000-05:00

I just added a fantastic blog that I follow, Mountain Runner. It's a blog about "public diplomacy", which is perhaps a mysterious term to the uninitiated. There are several discussions about the differences between, or tensions between, "public affairs", "information operations", and "public diplomacy". It seems to me, from the outside, that this debate over the proper roles and responsibilities of practitioners of each is somewhat like the false debate about the definition of terrorism. Definitions are symbols produced by their users which validate their perspectives and cause further definition of the environment. The point of bringing this up here is that information--whether it's passive or purposeful, to U.S. or outside audiences--is important. We can leave the definitions to the communities that struggle with them and focus on information communication for our purposes. While the topic of information-flow might seem tangential to the triad of health-national security-international relations that I propose to cover in this blog, it's not. Actions convey information, and lately I have been formulating a theory that a center of gravity for the GWOT might not really be "public opinion" since defining publics and their opinions during military operations is difficult. A center of gravity for the GWOT might instead (or additionally) be primary symbols. Recall the photos and TV coverage of soldiers pulling down the statute of Saddam Hussein in Baghdad. Simple example, but it conveys the point that symbols are powerful.

The use of information to actively change opinion might be more powerful if we understood the symobology of other people. The Assistant Secretary of Defense for Health Affairs sponsored a symposium on Culture, Health and Human security last week and two of the speakers discussed cultural creation of symbols. For example, I learned that there is a relatively specific culturally-derived view of women and health in the Jewish community. It strikes me that health, being at the very bottom of Maslow's hierarchy of human needs, is also perhaps a striking symbol that we should more carefully consider.

On December 12, the USS Kearsarge and USS Boxer will return to the U.S. after a trip to Latin America and the Caribbean where the staff delivered medical and veterinarian assistance to eight nations. There will be a media event at the University of Miami. Here's where there is more information: http://www.southcom.mil/appssc/index.php. These missions are designed to "foster goodwill and demonstrate U.S. commitment and support to Latin America and the Caribbean" according to the U.S. SOUTHCOM website. However it remains to be seen if these missions, which are being conducted in partner with other U.S. government partners like Health and Human Services, NGOs like Project Hope, and which are coordinated with the involvement of the public diplomacy community, are effective or efficient at communicating goodwill. It might be more effective, and more efficient, to examine the health symbols of the countries we visited and try to understand if there is a way to positively influence those symbols. This is not to say that these missions --the Comfort and Mercy included--are bad. It's easy to speculate from the comfort of one's own computer desk chair. However these missions are expensive and are using military resources so the question is a valid, if somewhat academic, question.

Switching focus to American audiences, the U.S. public is relatively unaware of these missions, which is unfortunate since we are a nation that likes to do good. And also a nation that likes to support its military. As symbols of both the military and our best wishes for the rest of mankind, these missions most likely could communicate powerfully to the American public. The current media focus seems to be on Latin American publics instead of the American public, oddly.

Consideration of symbols of cultures, and operationalizing a plan for communicating our intentions goes together. Creating good health for people around the world seems to be benign at worst, but are we sure?

What's mendstate?

2008-12-06T17:06:00.001-05:00

This blog is being created to discuss trends in the 'securitization' of 'health'. What does that mean? Well, I plan to discuss the health treatment of foreign nationals (and their health systems) by our military (and by coalition partners) as part of either a security operation, a stability operation, a transition operation or a reconstruction operation. SSTR-operations (SSTRO) is the new US military acronym for something that has been around for a long time and which has other names du jour like "nation building" or "winning hearts and minds" depending upon the context. Everyone tosses these words about as if they are synonomous, which of course they aren't. But much like trying to define "terrorism," the definition and action of 'nation building' to one person could be considered 'imperialism' to another. And that leads me to legitimization. I'm pretty certain I'll touch on ideas of 'legitimate' action --or when the world's public and the American public thinks the military and the government is acting righteously. Polls show positive response to our continued delivery of aid. Using the military to deliver humanitarian medical assistance post-conflict (as an example) might be perceived as being legitmate by some. On the other hand using the military to deliver medical humanitarian aid to 'stabilize' a country might not be perceived to be legitmate by those same few who would stop to consider. In it's bid to charm the rest of the world, how will American use its instruments of national power? And, particularly, how will global public health be affected, how will America be perceived? How effective can we be in doing our good deeds?

Foreign policy, global health and national security hang together quite naturally as do an egg white and an egg yolk. But oddly enough there is scant scholarship about the matter. Part of the problem is that although these ideas form a cogent and intuitively balanced perimeter, it is really hard to know what goes in the perimeter or when you have enough in the perimeter. Measuring traditional national security policy actions tends to be most persuasive in binary terms: either we win or they win. Foreign policy is much fuzzier since probably nobody quite wins everything, in absolute. But perhaps all sides gain a bit and hopefully lose a bit less. Global public health, which one would imagine could be defined by matters of counting (as in the number of people who are diseased), is even fuzzier. Different cultures define health differently than we do in the West. Not only that, but it's just plain hard to count much of anything in the middle of a conflict. Hence describing, measuring and furthering the practices of foreign policy, global health and national security (when taken as one), becomes darn near impossible. How do we know when we have reached an end state?

And that brings me to the name of the blog which is a play on words for mending, and state, and end state. What's the end state when you are mending a state? Or even mending non-state actors? Very hard to know. But really interesting to consider.